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PRINCIPLES or MEDICINE: 



COMPRISING 




GENERAL PATHOLOGY AND THERAPEUTICS, 



AND A BRIEF GENERAL VIEW OF 



ETIOLOaY, KOSOLOG-Y, SEMEIOLOQY, DIAGNOSIS, 
PROGNOSIS, AND HYGIENICS. 



.^ 



BY 



.V 



CHARLES J. B. WILLIAMS, M.D., F.R.S., 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS j 

LATE PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE, AND OF CLINICAL MEDICINE, 

AND FIRST PHYSICIAN TO THE HOSPITAL, UNIVERSITY COLLEGE, LONDON ; 

CONSULTING PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST ; 

LATE PRESIDENT OF THE PATHOLOGICAL SOCIETY OF LONDON, ETC. 



EDITED, V/ITH ADDITIONS; 
BY MEREDITH CLYMER, M.B., 

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; 
LATE CONSULTING PHYSICIAN TO THE PHILADELPHIA HOSPITAL, ETC. ETC. ETC. 



J^^ 



i^onrti] American ©biiion, HcdIscD. 





PHILADELPHIA: 

BLANC HARD AND LEA. 
1853. 



Entered according to the Act of Congress, in the year 1S53, by 

BLANCHARD AND LEA, 

in the Office of the Clerk of the District Court of the United States in and for the Eastern District 

of Pennsylvania. 



LC Control Number 




tmp96 029110 



PHILADELPHIA : 
T. K. AND P. G. COLLINS, PEINTERS. 



^n 



TO THE 

PATHOLOGICAL SOCIETY OF LONDON 

IS INSCEIBED, 



THE AUTHOE. 



PREFACE OF THE AMERICAN EDITOR. 



In the preface of the first American edition, it was remarked that 
" a work on General Pathology supplies a want in English medical 
literature." The rapid sale of three large editions of the "Principles 
of Medicine," and the great favor with which it has been received by 
the profession, confirm this opinion. It possesses the strongest claims 
to the attention of the medical student and practitioner, from the ad- 
mirable manner in which the various inquiries in the different branches 
of pathology are investigated, combined, and generalized by an expe- 
rienced practical physician, and directly applied to the investigation 
and treatment of disease. 

The publication of Professor Chomel's classical Elemens de PatJio- 
logie G-enerale^ translated by Drs. F. E. Oliver, and W. W. Morland, 
of Boston, and of Dr. Still^'s "General Pathology," since that time 
— both valuable accessions to our literature — has not superseded the 
necessity of the present work. From their more limited plan, they 
treat chiefly of Etiology, Nosology, Semeiology, Diagnosis and Progno- 
sis ; whilst the Nature and Constitution of Disease — the chief subject- 
matter of the following pages — is scarcely touched upon. The scope 
of a work on General Pathology has been thus correctly defined: " The 
legitimate object-of a work on General Pathology is the study of dis- 
eases in the abstract, and in that which they have in common. It 
should serve as a complement to special and descriptive pathology, just 
as general anatomy does to descriptive anatomy. It should comprise 
all that is most simple and most elevated in science ; on the one hand, 
the definition of the terms, and the description of the phenomena of 
diseases ; on the other hand, the discussion of all the fundamental 
questions, and the exposition of the general principles which should 
serve to guide the physician in the arduous exercise of a profession so 
intimately connected with the dearest interests of humanity. General 



VI PREFACE OF THE AMERICAN EDITOR. 

Pathology, in fact, includes within itself the humblest elements, and 
the most sublime philosophy of medicine."^ 

The chief additions by the editor will be found in the sections on 
Etiology, Diseases of the Constituents of the Blood, Nutrition, Semeio- 
logy. Prognosis, and Hygienics. The section on Semeiology has been 
greatly enlarged, and an abstract of the general signs of disease added. 
The editor's matter is distinguished thus : [ — C] M. C. 

Philadelphia, June, 1853. 

^ Medico-Chirurgical Keview, 1843. 



PREFACE 



More than a year has elapsed since the first edition of this work was 
out of print, and it has been the subject of continual regret on my part 
that my engagements have so long retarded the completion of the pre- 
sent. Some excuse for the delay will, I trust, be found in the very 
extensive additions which it contains, comprising the enunciation and 
application of most of the facts and established deductions made avail- 
able to the science and art of medicine during the last few years. 
These additions pervade almost every portion of the work ; but they 
preponderate in the following subjects : — 

In Etiology, mechanical^ chemical^ and dietetic causes of disease^ de- 
fective cleanliness^ ventilation^ and drainage. In Pathology, the tabular 
views of the elements of disease; reflex action and sympathy ; elementary 
changes in thehlood; congestion; determination of blood; inflammation, 
in its nature, manifold results, and modes of treatment ; degeneration of 
textures ; cacoplastic and aplastic deposits, and their treatment, with a 
notice of the action of the cod-liver oil; and the whole chapter on 
Sygienics, comprising food, clothing, air and temperature, exercise, 
mental occupation, sleep, and excretion. 

In endeavoring to adapt the work to the rapid improA'ements in medi- 
cal science, it is most satisfactory to be able to state that in very few 
instances has it been necessary to retract or supersede the inferences 
and views set forth in the first edition ; on many subjects they have 
been confirmed and extended by recent researches to a degree that has 
not less surprised than convinced me of their truth ; as examples, I 
would mention the subjects Congestion, Dropsy, Determination of Blood, 
Inflammation, and Deposits. I am quite aware that my views on some 
of these subjects are opposed to those held by several distinguished and 
estimable pathologists ; and the knowledge of this fact has led me to 
test them the more severely by all the experiments which physiology, 
clinical observation, and pathological research could supply; and the 



Ylil PREFACE. 

result of this scrutiny, in wliicli I have been aided by several able friends 
and. pupils, has been a firmer and clearer conviction of their substantial 
truth. I would farther add, in favor of the views put forth on the above- 
named subjects, that thej, as it were spontaneously, point to remedial 
measures closely corresponding with those which the best experience 
has sanctioned, and they Amplify and facilitate the indications of treat- 
ment in a manner that suggests more efficient modes of practice than 
could be obtained by blind experience. 

It is in harmony with the statement just made, that whilst I feel 
grateful for the approbation with which this work has been honored by 
scientific men, both in this and in foreign countries, I am especially 
gratified by the favor with which it bas been received by practitioners 
of great experience. This favorable reception, as well as the assistance 
which it has afforded me in my systematic course of lectures on practi- 
cal medicine, leads me to believe that my attempts to combine science 
with art, to place the practice of physic on a more rational basis, have 
not been altogether unsuccessful, and encourages me to hope that the 
present work may farther contribute to the same desirable end. 

I am fully aware of the existence of many defects in the accomplish- 
ment of this work, some of which might be amended by delaying its 
publication a little longer ; but the objections to such delay outweigb 
the probable advantages ; and I must trust to the leniency of my critics 
to excuse the errors of omission and commission, whicK it is very diffi- 
cult to exclude in a volume that is at once elementary and yet embraces 
a most extensive range of subjects. 

7, Holies Street, Cavendish Square^ 
Feb. 19, 1848. 



PREFACE 

TO THE FIUST EDITION 



As an apology for the appearance of tliis publication, it may, I think, 
be stated to be generally acknowledged, that there is at present, no work 
which fully treats of the subject of General Pathology, and its applica- 
tion to practical medicine. The present attempt to supply the defect 
arose from my feeling the want of an elementary work on these sub- 
jects, by aid of which I could introduce to my pupils the science of 
practical medicine. With many excellent and elaborate treatises on 
the details of medicine, we have scarcely any which treat of those 
general principles in the nature and treatment of disease, which are 
really fundamental in the practice of medicine. Even the very able 
work of my distinguished friend. Prof. Alison (to which the following 
pages owe much), in the last edition, instead of some of these general 
principles, embraces some of these details of Special Pathology. 

It may be supposed, that in subjects comparatively so modern as 
those embraced in this work, little reference can be made to any but 
recent authors ; and for a great portion of the facts and illustrations, I 
have drawn on my own experience in the continual observation of dis- 
ease, during upwards of twenty years, in hospitals and private practice. 
Throughout this experience, I have always endeavored to keep in mind 
the bearings of physiology and pathology on practical medicine, and to 
render their advances useful, by their application to this art. Many 
original facts and opinions have been the result of this mode of study ; 
and some of these will be found in the following pages. I cannot 
expect that they will speedily receive a general assent ; but I ask for 
them the test of clinical observation, from which they have been 
mainly derived. 

It seems quite extraordinary that, notwithstanding the recent rapid 
improvenients and comparative perfections of the contributory sciences, 



X PREFACE. 

practical medicine should still halt in the domain of empiricism.. A 
chief reason for the anomaly seems to be, that science and practice 
have been rarely pursued by the same parties. Scientific men are not 
and cannot be practical, because they have had no experience ; and 
practitioners know little of science, and therefore derive little good 
from it. Instead of working together, these parties are at issue with 
each other. But it is high time to put an end to this feud. Philoso- 
phers must descend from their transcendental positions, to consider 
details of practice and purposes of utility. Those who would be prac- 
titioners, must gain from science that knowledge and that method 
which render experience instructive and useful. 

In the present effort towards the accomplishment of these objects, I 
am conscious of many deficiencies. Want of time has prevented me 
from treating some subjects as fully as they deserve, particularly those 
of the last chapter. In others, I have studied to be brief, to avoid 
perplexing the reader with much discussion or detail. For this reason, 
doubtful facts and a variety of conflicting opinions have been withheld ; 
and only the facts best ascertained and the views which seem most 
tenable have been given. By this eclectic method, I have succeeded 
in reducing a very extensive range of subjects within the compass of a 
moderate volume. 

7, Holies Street, Cavendish Square, 

Sept. 22, 1843. ■ ' 



CONTENTS 



Preface --------- Page v 

PRINCIPLES OF MEDICINE. 

Paragraph. 

Explanation of the Subjects of the Work - - - p. 33 

1, 2 Principles of medicine. Synonymes, Whence deduced. Division into etiology, 

3, 4 pathogeny, general therapeutics, and other subjects - - p. 33 

Definition of Disease - - - - - - p. 33 

5 Standards of comparison. Definition of health. Deviations from health ; in 

function ; in structure. 

6 Physiology a standard of healthy function ; anatomy — of structure. 

7 Definition of disease, 

8 Variations in the standard of health. Examples. 

CHAPTER L— ETIOLOGY— ON THE CAUSES OF DISEASE. 
Section I. — Nature and Division of Causes - - - P- 36-39 

9 Definition of causes of disease. Antecedent circumstances apt to be mistaken 

for causes. This error to be avoided by proving their occasional absence, and 
investigating the intimate nature of disease. Example. 

10 Causes of disease intrinsic and extrinsic. Examples. 

11 Causes of disease not sure in operation; except those which are very strong. 

12 They generally require predisposition. Examples. 

13 Causes divided into remote and proximate. Remote divided into predisposing 

and exciting. 

1 4 Co-operation of predisposing and exciting causes generally necessary. Examples. 

Exceptions. 
16 Predisposition generally deficiency of natural power of resistance. Examples of 

the operation of this resisting power. 

18 Predisposition from error of function or structure. Other terms for predisposing 

19 causes; why sometimes inapplicable. Causes are circumstances inducing 
disease. 

Section II, — Predisposing Causes of Disease - - - P- 39-53 

Classification of predisposing causes. 

I. Debilitating causes and their modes of operation. Imperfect nourishment. Im- 
pure air. Excessive exertion of body or mind. Want of exercise, and seden- 
tary habits generally. Long-continued heat. Long-continued cold. Habitual 
intemperance. Depressing passions. Excessive evaciiations. Previous de- 
bilitating diseases. 

II, Excitement, examples. III. Previous disease; operating by change of struc- 
ture ; by persistence of cause. Examples. 

IV. Present disease or defective function. 



20 




21, 


22 


23 




24 




25- 


-28 


29, 


30 


31, 


82 


33 




34, 


35 



XU CONTEXTS. 

Paragraph. 

36, 37 V. Hereditary constitution. YI. Temperaments. Definition and nature ; sanguine ; 
38-41 phlegmatic; bilious; nervous. Diathesis. VII. Age, and its ijredisposif ions. 

42-46 Infancy. Childhood. Puberty. Full-growth. Adult age. Old age ; influ- 

47-49 ences exemplified in vascular and nutritive functions. YIII. Sex. IX. Occu- 

50 pation. 

Section III. — Exciting Causes of Disease - - - p. 53-80 

51 Operation of exciting causes. Division into cognizable and non-cognizable. Clas- 

sification. 

52 I. Cognizable Agents. (1.) Mechanical causes: examples of their physical 

effects. Vital operation of severe injiuies. 

53 (2.) Chemical causes : eixtrinsic ; intrinsic; modes of operation, as local irritants, 

as corrosives, as septics, and as chemical alteratives ; examples of theii' eifects. 
54,55 (3.) Ingesta. Non-alimentary: examples; action of salt in excess. Intoxicating 

56 liquors, use and abuse of. Delirium tremens ; principles of treatment. Adul- 

57 terations of food, impure water, medicines. Aliment, unfit in quality; a due 

58 mixture requisite. Simple principles, such as fibrine, starch, gum, &c., insuf- 
ficient. Bread the stafi" of life. Dr. Front's views on aliments, sanctioned by 

59 familiar experience. Extent of conversion of the elements of food by digestion. 
Dumas's views ; objections. Experiments of Fetroz and Boussingault. Liebig's 

60, 61 views. Effects of alimentary principles ; albuminous, gelatinous, oleaginous, 

and saccharine, in defect, in excess, or bad in quality. Aliment, generally, in 

62, 63 excess. Defective. Symptoms of inanition. Chossat's experiments on starva- 

tion. 

64 (4.) Violent exertion, efi'ect on the heart, brain, lungs, and other organs. Fartial 

65 exertion. Exhaustion froni fatigue. Want of exercise. 

66 (5.) Mental emotion. Strong. Slow emotion. Mental anxiety. Excessive men- 

tal exertion. 

67 (6.) Excessive evacuation. Effects. Syncope, cerebral and cardiac. Other efi'ects 

and resulting diseases. 

68 (7.) Retention, diminution, and suppression of evacuations, alvine, urine, bile, &c. 

69 Lower degrees common in disease. Suppression of artificial discharges ; of 
cutaneous eruptions, &c. 

70 (8.) Defective cleanliness, ventilation, and drainage. Their prevalence; modes in 

71 which they excite disease. Filth, action on skin, &c. Filth in dwellings. 

72 Defective ventilation often insidious in its operation. Evil results, in dwellings 

73 and public buildings. Defective drainage; results of eifiuvia from cesspools. 
London sewers. Untrapped drains. Causes and consequences, 

74,75 (9.) Temperature and changes. Efi'ects of extreme heat or cold. Extensive burns, 
shock. Cold, applied generally. Experiments of Sir A. Cooper and Chossat. 

76 Stimulating eflfects of heat. View of Liebig. Partial application of heat. 

77 Sedative efiects of cold. Intropulsion of blood. Efi'ect on the arteries. Indi- 

78 rect efi'ects of cold. Chilblains. Warmth to be restored in benumbed parts 

79 gradually. Mode in which cold excites internal disease. Dr. Alison's views: 
objections. It acts by deranging the circulation. Symptoms of "cold caught."' 

80 Means of diminishing susceptibility to cold. Cold bathing. Water-cui'e. 

81 Efi'ects of cold proportioned to previous state of the body. Atmospheric 
changes. 

Section IV. — Non-cognizable Agents - - - - P- 80-90 

Definition and division into Endemic, Epidemic, and Infectious. 

82 (I.) Endemic causes. Proofs of their existence. Sources. Malaria. Nature of 
83, 84 malaria. Its properties. Sources of malaria. Its virulence in proportion to 

85 heat with moisture. Morbid effects of malaria. Periodicity of their attacks, 

86 cause of this, Ivinds of malaria. Endemic disease from cognizable causes. 
87,88 (II.) Epidemic causes. Proofs of their existence. Epidemic. Cognizable causes 
89, 90 distinguished from non-cognizable. Epidemic constitutions or periods. Na- 

91 ture of epidemic influences. Dr. Front's observations. Animalcule origin of 

92 epidemic diseases. 

93, 94 (III.) Infectious causes. Proofs of their existence. Modes of infection: by 

95,96 wounds; by contact; by aerial commimications; by several modes. Difiicul- 

97,98 ties of explaining infection. Analogy of fermentation; of animal and vegetable 

99,100 generation; examples. Parasitic view of infection confirmed by circumstances 



COXTENTS. Xm 

Paragraph. 

101 wliich promote and check it. Peculiarities of infectious diseases, of endemic 

102-104 diseases, of epidemic diseases. Diseases propagated in several ways. Pesti- 
105 leuces. General opei-ation of all these causes depressing, but may excite re- 

action. Effect modified by the "weather. 



CHAPTER II.— PATHOLOGY (PROPER)— THE NATURE AND 
CONSTITUTION OE DISEASE. 

106 Disease composed of elements. Analogy with chemistry, &c. Primary ele- 

107 ments of structure and function ; healthy and diseased. Primary elements 

108 of disease. Alterations of these elements in degree, and in kind. Table of 

109 primary elements of disease. Table of proximate elements of disease; in 

110 excess, defect, and perversion. These elements are the especial objects of 
general pathology ------ p. 91-93 

FUNCTIONAL DISEASES.— PRIMARY ELEMENTS. 
Section I. — Diseased Ikritabilitt - - - - p. 93-9G 

111 Irritahility. The distinctive property of muscular fibre. In excess. Varieties 
112-114 in strength, in mobility, and in duration. Examples, causes. Remedial 
115 , measures. 

116-118 Defective, in force, in mobility. Connection of irritability with nerves not es- 

119 sential. Remedial measures. 

Section II. — Diseased Toxicity - - - - P- 96-99 

120 Tonicity; distinct from irritability; proved by different effects of heat and cold. 

Long known empirically. 
121,122 Excessive. Examples: effect on pulse. Remedial measures. 
123,124 Defective. Examples: retarded and dichrotous pulse. Remedial measures. 

Section III. — Diseased Sensibility - - - - P- 99-105 

125 Sensibility referable to the nervous system, and divided into general and local. 

126 General. Excessive, from excitement, from disease, from temperament. Patho- 
127,128 logical causes. Remedial measures. Inhalation of ether; mode of action. 

Inhalation of chloroform, see Appendix. 
129, 130 Defective. Causes; from disease, age, temperament. Remedies. 

131 Perverted. Examples; causes. Remedies. 

132 Local sensibility. Variations illustrated by experiment. Pathological causes. 
133-136 Excessive, in orifices, in internal organs. Pain, and other varieties. Reme- 
137, 138 dial measures. Defective. Paralysis of sensation. Remedies. 

Section IV. — Diseased Voluntary Motion - - - P- 105-108 

139 Division into general and partial. 

140, 141 General voluntary motion, in Excess: examples. Defective: examples. Per- 

142 verted: examples. 

143, 144 Partial, excessive, rare. Defective; pathological causes: examples. Remedies 

145-147 for diseased voluntary motion ; excessive. Defective local. Perverted. 

Section V. — Diseases of Reflex and Sympathetic Nervous In- 
fluence ----- p. 108-114 

148,149 Natural reflex function : examples. jKccess^ye, in involuntary muscles; exam- 
150, 151 ples> In voluntary muscles : examples. Convulsions: centric and eccen- 

152 trie. Partial, by reflected irritation. Irritation of involuntary muscles- 

153 the spinal marrow the centre of reflexion. Pathological causes of inordinate 
excito-motion; irritation of spinal marrow or its nerves; accumulation by 
rest; from action of opium, &c. 

154 Defective reflex motion. In coma, asphyxia, sinking, &c. Ptemedial measures 

155 for excessive. Narcotics, sedatives, stimulants, tonics. For defective. Sti- 
mulants; opium. 

156, 157 Reflected or sympathetic sensations. Examples. Remedies. 



XIV CONTENTS. 

Paragraph. 

Section YI. — Diseases of Secretion - - - P- 114-122 

158 Secretion due to a Yital property, aided by cliemical affinity; not to be ascribed 

to nervous influence. 

159, 160 Changes due to altered supply of blood, or to nervous influence. Excessive. 

161-161: Efi'ects; forwards; examples; backwards. On the organ; examples. On 

165, 166 the blood; examples. Remedies. Depletion. Astringents. Alteratives. 

167-169 Defective secretion. Causes. Efi'ects; forwards; examples; backwards; on the 

170,171 organ; examples. Suppression of excretions; extreme, moderate; inidio- 

172, 173 pathic and symptomatic fevers, and other diseases. Remedies, through the 

174, 175 circulation. Special stimulants. Alteratives. Tonics. Substitutes for 

176-178 defective secretion. Perverted secretion. Examples. Efi'ects. Remedies. 

Section VII. — Diseases of the Constituents or the Blood p. 122 

179 Constituents of the blood, when altered, form elements of disease. 

180, 181 Enumeration of constituents and modes of alteration. Chemical composition 
of the blood. 

Diseases of bed Particles - - - - " P- 123-129 

182-184 Natural offices and proportions. Excess. Examples. Signs -and efi'ects. 
185, 186 Defective. Examples, and efi'ects. Alterations; in color; in shape and size; 
187,188 breaking up. Arterial change; cause. Mulder's notion. Mr. W. Jones's 

189,190 observations ; explanation. Mr, Gulliver's observations. Origin of red par- 

191-193 tides. Causes of their decrease. Disorders of spleen and uterus. Reme- 

dies for excess, defect, and alteration. 

Section VIII. — Fibrine and white Corpuscles - ~ P- 129-140 

194 Nature of fibrine. Purposes. Structure, in washed clot, or lymph; composi- 

195 tion. Excess. Examples; signs and efi'ects. Increase of white globules. 
196,197 BufFy coat present without excess of fibrine. Defect. Examples ; fluidity of 
198 blood. Causes. Efi'ects; hemorrhage, congestion, venous murmurs, &c. 
199-201 Alterations in quality; apparent from character of coagulum, which shows pro- 
202 perties of self-coagulation, contraction, and separation. Self-coagulation ; va- 
203,204 rieties and causes. Contraction; varieties and causes. Separation; causes, 
205, 206 varieties. Causes of the buff'y coat. Appearances of coagulated blood. 
207, 208 Large clot; small clot. Separated and cupped; mode of exhibiting these 
209, 210 properties. Source of fibrine, and formation of white globules. Increase 
211, 212 by inflammation. Material of coagulable lymph. Varieties. Coagulation 
213 of fibrine during life. Vegetation and polypi. 

214, 215 Remedies for excess of Fibrine. Bloodletting. Evacuants. Mr. Blake's ex- 
periments. 
216 Diet. Remedies for defect; diet; regimen; stimulants; tonics; antiseptics. 

217-219 Means of altering quality of fibrine ; depletion; alteratives. Tonics; diet. 

Section IX. — Albumen and other Animal Principles dissolved in 

THE Serum ------ p, 140, 141 

220 Natural offices of albumen. 

221, 222 Excess. Examples. Causes. Remedies. Defect. Examples. Efi'ects. Remedies. 

Section X.— Oil p. 141, 142 

223, 224 Excess. Examples. Milky serum. Depends on the presence of unassimilated 
chyle. Cholesterine. Causes. Sources of fat. Causes of obesity. Reme- 
dies. Defect. Cause of atrophy. 

Section XL — Saline Matter - - - - P- 142, 148 

225-227 Excess. Thirst caused by salt. Z>e/ec<.- in yellow fever and malignant cholera. 
Effect of saline injections. Use of salines in fevers. Defect of potash the 
cause of scurvy. See Appendix. 

Section XIL— Water. ----- p. 143-145 

228-230 Excess. Examples and effects. From too much drink. Defect. Examples. 
231 Symptoms. Causes. Effects of cholera — of abstinence from liquids. Re- 

medies for excess and defect. Water-cure and dry diet. 



CONTENTS. 



XV 



Paragraph. 

232-234 

235, 236 

237 

238 

239 

240 

241, 242 

243 

244-246 

247 



Section XIII. — Changes in the Blood by Respiration - p. 145-150 

Analysis of the changes. Excess. Examples in disease? Defect: the element 
of asphyxia. Effect proportioned to suddenness as well as degree. Explana- 
tion of this. Analysis of asphyxia. Classification of symptoms. Defect 
gradually induced. Hybernation. Cyanosis: state of the functions; little 
muscle and much fat; with defective respii-ation. Emphysema. Remedies 
for defect ; lowering functional activity. Treatment of asphyxia. Stimu- 
lants. Warm bath. Promoting respiration. Other means of arterializing the 
blood. Treatment of congestion of apnoea. Diet in dyspnoea. Excess of 
changes by respiration: in rheumatism ? Respiration of oxygen gas. Effects 
explained. Carbonic acid may asphyxiate independently of the exclusion of 
oxygen. Liebig's theory of the action of hydrocyanic acid controverted. 



Section XIY. — Changes in the Blood by Excretion 



150-153 



248 Defective secretion of urine. Experiments of Prevost and Dumas, of Bernard 

249 and Barreswil. Effects of diseased kidneys. Acute and chronic albuminuria. 

250 Defective secretion of bile. Examples. Effects. Of perspiratory secretion ; 

251 checked by cold. Vicarious action of skin and kidneys. Rheumatism ; 

252 materies morbi. Remedies to be directed to this element. 

Section XV. — Changes in the Blood from the Transformation of 

Chyle and of the Textures - - - " P- 153-158 

258 Natural changes uncertain. Lithic acid diseases. Diet, &c. producing them. 

254 Operation of colchicum. Effects on the kidneys. Nephralgia, &c. Gout; 
varieties, effects. 

255 Formation of sugar in diabetes. Effects and treatment in gout and rheumatism 
256-258 contrasted. Production of urea in excess. P\-emedies. Obesity. Fatty de- 
generation. 

Section XVI. — Changed Properties of the Blood from the Pre- 
sence of Foreign Matters - - - - P- 158-159 

259 The blood the seat of morbid poisons ; proofs ; and of germs of malignant dis- 

260 ease. Treatment of morbific matters in the blood. 



CHAPTER III.— PROXIMATE ELEMENTS OF DISEASE. 



Section I. — Anemia 



p. 160-1{ 



261 Explanation of proximate elements of disease. 

262-264 General anaemia. Nature, exciting causes, and symptoms. Physical signs. 

265-267 Changes in the blood. Symptoms of excitement in anaemia. Explanation of 

268, 269 these symptoms. Symptoms of coma, &c. Cases and interpretation of na- 

270,271 ture of anaemic coma. Nutrition in anemia. Fatal terminations. Remedial 

272 measures. Regimen and diet. Medicines. Venous murmurs. 

278 Partial anaemia. Examples. Effects. 



274 



Section II. — Hyper^emia, or Excess of Blood 
Definition and nature. Classification of varieties. 



Section III. — Plethora — General Excess of Blood 



p. 169-173 



275-277 Origin of plethora. Subjects. Symptoms. Tendencies. Causes. Division 
278, 279 into Sthenic and Asthenic. Symptoms of Sthenic. Subjects. Tendencies. 

281-283 Asthenic. Symptoms. Subjects. Tendencies. Results. Fever. Gout. 

284-286 Remedial measures. Bloodletting: where unfit. In sthenic, other mea- 

sures needed. In asthenic, tonics as well as evacuants. 



XVI CONTENTS. 

Paragraph. 

Local Hyperemia, Excess of Blood ix a Part. 

Section IV. — With Motion diminished - - ~ P- 173-188 

287, 288 Congestion, analyzed. Its causes classed. 

289 Congestion from venous obstruction. Examples, in health and in disease. Ex- 

planation of congestion in emphysema. 

290 Congestion from atony of the vessels. From general debility. Hgpostatic. From 
291, 292 over-distension. Examples. From intropulsive action of cold and malaria. 
293, 294 Over-excitement or inflammation. Examples and illustrations by microscope. 
295, 296 Stagnation in the vessels. From arrest of secretion or capillary circulation. 

298 From imperfect respiration. (Power of the heart sufficient of itself to main- 
tain the circulation. Dr. Sharpey's experiment. Microscopic examinations: 
fallacies. Objections to the supposition of spontaneous movement of the 
blood-particles.) Observations of Mr. Erichsen. Obstruction to circulation 

299 in asphyxia is from contraction of the small arteries. Atony of vessels im- 
300-302 pedes transit of blood. Experiments to show the neutralization of force in 

the flaccid vessels. Cause of long continuance of congestion. 

303 Symptoms and effects of congestion. Effects on secretion explained. Production 

305, 306 of flux. Examples. Considerable congestion required to produce dropsy. 

307 Amount of tension and quality of blood determine quality of effusion, liquid 

308 and solid. Examples. Albuminuria referred to congestion of the kidney. 
309, 310 Reasons. Congestion continuing, causes hypertrophy of a peculiar kind. 
311, 312 Origin of granular disease and cirrhosis. Other instances. Effects of local 

congestion on the system. 
313 Remedies for congestion. Removal of causes, venous obstruction and causes of 

314,315 atony. Posture. Pressure. Friction. Exercise. Astringents and tonics ; 

316,317 when inapplicable. Stimulant remedies. Operation shown by the microscope; 

318 when hurtful. Depletion and other evacuants. Hsemostasis or counter con- 

319, 320 gestion. Preceding remedies combined or alternated. Prevention of con- 

gestions by increasing tone. 

Section V. — Local Htperjemia. Excess of Blood in a Paet, with 

Motion increased. Determination of Blood - - P- 189-198 

321,322 Examples in health and in disease. Determination to the head. Examples with 

324, 325 symptoms. Caused by stimuli. Physical cause of determination of blood. 

326, 327 Enlargement of arteries proved, by experiment and microscope. Dr. Billing's 

328, 329 view. Cause of the enlargement, a loss of tonicity. Final cause of deter- 

330 mination to supply more blood where wanted. Determination from intro- 

331 pulsion. Subjects of determination. Determination may cause anasmia in 

332 other parts. Determination affects large arteries. 

333, 334 Symptoms and effects of determination of blood. Parts most subject to it. To the 

335, 336 head. Explanation of its different effects in different cases. To the kidneys, 

337-340 To the mucous membranes. To the skin. Other symptoms. Determination 

341 if continued leads to hypertrophy. 

342, 343 Remedies. P^emoval of causes. Means which promote the tonic contraction of 

344-346 dilated arteries. Cold. Astringents. Derivants. Posture. Evacuants. 

Bloodletting; general and local; its effect seen by the microscope. Cases 

347, 348 requiring bloodletting. Remedies to relax the arterial system and quiet the 

349 heart. Measures to equalize and strengthen the circulation. Tonics. 

Section VI. — Results or HrpERjsMiA - - - P- 198-218 

350 Hemorrhage, flux, and dropsy, results short of inflammation. 

351 Hemorrhage from j9/e//io;'a. Examples. Epistaxis, hematemesis, &c.,/ro7n co?i- 

352 gestion of venous obstruction. Examples. Pulmonary, bronchial, gastric, &c. 

353 From atony of vessels: from posture; from intropulsion of cold. Examples. 
354,355 '¥Yom determination of blood. Examples. Epistaxis; apoplexy; hematemesis. 
356 Additional element of hemorrhage in the vessels or in the blood. Blood- 
357, 358 vessels diseased. Examples. Blood diseased. Hemorrhagic diathesis. Mode 
359 in which blood is effused. By ruptui'C or through pores? 

360, 361 Varieties of hemorrhage. Sthenic and astlienic defined. Symptoms. 3Iolimen 

362 Ae?7io7T/my2cw?rt; jerking pulse, how produced. Faintness; Reaction. Transi- 

363, 364 tion to inflammation. Examples. Local effects and symptoms. Passive 

365 hemorrhage. 



CONTENTS, XVll 

Paragrajjli. 

366, 367 Treatment of liemorrliage. Remedies for hypergemia. Styptics. Cases re- 
368, 369 quiring a speedy check. Actire or sthenic. Passive or asthenic. Mecha- 

370 nical means. Special styptics. Internal remedies. Tonics, purgatives, 

and styptics. 

373-375 Flux and Dropsy. From plethora. Examples. From congestion. Experi- 
ment of Lower. Examples in disease. 
376-378 From weakness of the vessels. After excitement. Intropulsion of cold. 
379 'Ftotq. determination of blood. Examples; active flux; active dropsy. 

380-382 Flux and dropsy vicarious. Examples. Circumstances causing hyperemia to 

383 end in these results : in the vessels : in the blood. Combination of these 

384 circumstances in ansemia. Diseased blood from defective excretion, espe- 
cially by the kidneys. Examples and proofs. Causes of anasarca after scar- 

385 latina. Dropsy and flux with albuminuria: why inflammatory : resemblance 

386 to rheumatism. Thinness of blood cause of asthenic dropsy. Dropsy from 

387 retention of water and excrementitious matter in the blood. Malnutrition. 
388, 889 Proofs. Distinctive pathology of fluxes and di'opsy. Causes of each. 

390 General treatment of flux and dropsy. Remedies for hypersemia. Ptemedies for 

391 malexcretion and malnutrition. 

392,393 Treatment of fluxes. Removal of causes. Derivants. For sthenic flux; evacu- 

394 ants and depletion; not to be hastily checked. For asthenic flux; astrin- 
gents and tonics. Dry and tonic regimen. 

395 Treatment of dropsy. Means to remove effusion and restore action of kidneys 
396, 397 in sthenic dropsy. Means to improve the blood in asthenia. Recurrence of 
398 dropsy requires variation of remedies. Circumstances which indicate tap- 
ping or puncture. Cautions. 

Section VII. — Lc^\l Hyperemia, Excess of Blood in a Part, with Mo- 
tion PARTLY INCREASED, PARTLY DIMINISHED — INFLAMMATION 

p. 219-295 

399, 400 Inflammation not understood from its elements not being studied. Definition 
from natui-e ; from signs. 

401 Causes op Inflammation and their Mode of Operation. Predisposing 

weakness or excitement. Exciting causes divided into local and general ; 

402 direct and indirect. Local irritants; mechanical, chemical, and vital. Exam- 
403, 404 pies. Indirect causes produce congestion. Causes mixed in operation. 
405, 400 Checked hemorrhage and flux. Irritants operate primarily on the nerves. 

407 But inflammation is sometimes excited without nervous irritation. Cause 

408 essentially acts on. vessels, producing sometimes determination first, some- 
times congestion. 

409 Phenomena and Nature of Inflammation. Difi'erence from congestion; 
410, 411 from determination. Essential characters established: increase of blood, 

with motion increased and diminished. Cause of the obstruction. Views of 
412, 413 Cullen, W. Phillip, Hu.nter, Kaltenbrunner, and Alison, considered. Atony 

414 of the vessels a partial cause of obstruction. Examples and experiments. 

415 Another cause within the vessels ; adhesion of white globules ; their increase. 

416 Description and production of white globules; Mr. Addison's observations: 

417 Mr. Gulliver's. Appearance of frog's web after irritation. Adhesive pro- 
perty of white globules; those recently formed have no cell-wall. Share 
which the red corpuscles take in the obstruction. The presence and proper- 

418 ties of white globules essential to inflammation. Conclusions as to the 
419, 420 obstruction of inflammation. EfiTect of obstruction to expend force on the 

421 arterial capillaries. This opposition of obstruction to force also the cause 
of destruction. 

422 EflFects of inflammation on vital properties ; on secretions. 

423,424 Efi'usions; general character; microscopic character. Exudation corpuscles. 

Elementary solids of inflammatory eff"usions. Molecules. Granules. Fibrils. 
425, 426 Exudation corpuscles. Pus-globules. Tubercle. Mode of formation of 

some of these. Variety in their plasticity and organizability. Other eff"ects 

427 of inflammation.- Softening. Suppuration. Slough. Gangrene. Induration. 

428 Symptoms and Effects of Inflammation. Divided into local and general. 
429, 430 Local Symptoms. Redness; causes; varieties; changes. Heat; cause; 
431, 432 indications. Swelling; causes; varieties from texture. Fain; causes. 



445, 


446 


447, 


448 


449 




450 




451 




452, 


453 


454, 


455 


456, 


457 


458, 


459 


460 




461 




462 





XVm CONTENTS. 

Paragrajjh. 

433, 434 Degrees and varieties and their causes. Other sensations. Effect of in- 

435, 436 flammation on contractility. On other functions and symptoms. 

,437 Constitutional Symptoms. Inflavimatory fever. Change in the blood. Cause 

438, 439 of the increase of the fibrine and its contractile property. This not the sole 

cause of inflammatory fever. Patholog}^ of inflammatory fever. Causes. 

440, 441 Reaction, irritation, altered condition of the blood. Why some functions are 

442 excited and others impaired. Symptoms of inflammatory fever. Its varie- 

443 ties : high, low. Type of fever from cause or seat of inflammation. Ex- 

444 planation of this. Remittent and intermittent fever. Apyrexia. Injury to 
blood in continued inflammation. 

Nature and Symptoms of the Results or Terminations of Inflammation. 

Division. The results seldom occru- singly. Resolution. Its nature. Modes 
of occurrence. Local symptoms. Constitutional symptoms of resolution. 
Critical discharges. Lateritious sediments; cause; natm^e; reason of ab- 
sence, &c. 

Effusion (including adhesion). Not always a termination. History of effusions 
in serous membranes. Coagulable lymph. Varieties. Euplastic. INIode of 
organization. Formation of vessels. Views of Riernan, Travers, Vogel, 
Listen. Cacoplastic lymph. Varieties and effects. Aplastic lymph. Causes 
of these low joroducts. Effusions of mucous membranes. Interstitial deposit. 
Changes of mucus. Effusion in skin: varieties of cutaneous inflammation. 
Effusion in cellular texture. In parenchymata. Symptoms of effusion. 

Supyuraiion and ulceration. Nature of pus. Microscopical characters. Dis- 
tinction between exudation corpuscles and pus. Alteration by acetic acid ; 
by distilled water. Its want of cohesion. Explanation of this. Liquefaction 
of tissiies in suppuration. Chemical changes. Causes of suppuration. Cir- 
cumstances tending to the conversion of the deutoxide of proteine into the 
tritoxide. 1. Intensity and contiuuance of inflammation. 2. Access of air. 
3. Suppurative diathesis. Examples. Mode in which they act. Pus in the 

463 blood. Process of suppuration explained: death of tissues by pressure ; 
liquefaction and absorption of all but pus-globules. Varieties of suppuration. 

464 Diffused. Abscess : pyogenic membrane : pointing. Opening and healing 
465, 466 of abscesses. Granulations. Ulceration. Varieties. Causes. Softening of 
467 textures. Suppuration a work of destruction, therefore depressing. Symp- 
468,469 toms of suppui-ation. Local: constitutional: varieties caused by limitation, 
470 . or not, of suppuration. Purulent deposits. Nature and causes. No true 

absorption of pus. Pus frequent!}'- in the blood in severe inflammation. 
471 Cacbffimia usually precedes pyccmia. Depression from suppui'ation. Cause 

of rigors. Plectic fever. Varieties of pus ; laudable ; ill-conditioned. 
473,474 Gangrene. Process of sloughing; gangrene; and sphacelus. Causes of gan- 

475 grene; interrupted circulation ; noxious agents. Local symptoms and effects 

476 of gangrene. Varieties. Constitutional symptoms. Combinations and gra- 
dations of the results of inflammation. 

Varieties or Inflammation. 

477, 478 Sthenic and asthenic ; sj-mptoms and results. Acute inflammation generally 

479 sthenic ; symptoms, duration, products. Subacute. Chronic ; generally 
asthenic; s_ymptoms, duration, results. Cause of their variety. 

480 Congestive inflammation ; nature, symptoms, results, 

481 Phlegmonous inflammation ; nature ; causes ; type and symptoms, 

482 Erythematic and er^' sipelatous ; local symptoms and effects ; fever; cause spe- 

483 cific. Pytemia, Pellicular; asthenic; sj^mptoms; low fever. Plastic in- 
flammation of mucous membranes. Aphthce of adults often attended by the 

484 growth of a confervoid vegetable. AphthoB of children. Hemorrhagic 
inflammation; causes. 

485 /S'r/-o///^o/«' inflammation ; asthenic; peculiar symptoms. Microscopic charac- 

ters of scrofulous matter. Changes which it undergoes. Scrofulous dia- 
thesis; its external marks; symptoms and causes. Course and results of 
'ISO. 487 inflammation in scrofulous subjects. Condition of the blood. Gouty and 

rheumatic inflammations. Nature and causes. Gonorrliaial inflammation; 
seat and effects. Syphilitic inflammation ; seat and eflects. 



CONTENTS. XIX 

Paragraph. 

488 Treatment of Inflammatiox, best understood from knowledge of its elements 

489 and of counteracting measures. Tabular view of constituents of inflamma- 
tion. 

490 Tabular view of the chief elements of inflammatory disease, and their reme- 

491 dies. Comments on these principles of treatment. Remedies for incipient 

492 • inflammation; 1, for congestion; 2 and 3, for irritation of nerves and vessels 

493 for established local inflammation ; for determination to the part ; 5 and 6, 

494 for obstruction in the part from atonic enlargement of the capillaries, and by 
adhesion of the white particles with accumulation and impaction of the red 

495 ones; 7, Distension of vessels; 8, for effusions from the vessels; 9, fovin- 
496, 497 creased absorption ; 10, for impeded circulation in the part ; 11, for increased 
498, 499 circulation around the obstructed part. 

500 Treatment of inflammation with fever. Local remedies secondary. Chief reme- 

501 dies, general iZoo(//c«m,y; efi"ect. Tolerance of bloodletting ; cause. Objects 
502, 503 and mode of bloodletting ; in recent inflammation ; in confirmed inflamma- 
tion; in inflammation with plethora ; in antemic subjects; substitutes. Local 

504 bloodletting ; uses. Evacuants; purgatives; combinations. Tartarizcd an- 

505, 506 timony ; modes of administration ; modes of operation. Mercury. Calomel 

507 and opium; modes of exhibition; modes of operation. Refrigerants. Sa- 

508, 509 lines. Sedatives. Diuretics. Counter-irritation, Antiphlogistic regimeu 

510,511 and diet. 16, Exhaustion. 17. Depression from poison. Remedies: their 

512 mode of action. Stimulants, antiseptics, tonics, &c. 18. Treatment for 
products of inflammation, liquid and solid. 

Tkeatmekt of Varieties of Inflammation. 

513-516 Sthenic. Asthenic. Acute. Subacute. Chronic. Congestive. Phlegmo- 
517-519 nous. Erysipelatous. Pellicular. Hemorrhagic. Scrofulous. Treatment 

620, 521 of the scrofulous diathesis and deposits. Cod-liver oil. Rheumatic and 

gouty. Gonorrhoeal and syphilitic. 



CHAPTER IV.— STRUCTURAL DISEASES ; OR DISEASES OF NUTRITION. 

Section I. — Nature and Classification - - - p. 296-299 

622 Arrangement of structural diseases. Table of elements. Structural disease 

623 often complicated. Modifications of natural nutrition. Material of nutrition. 
524 of fibrine. Modes and process of nutrition. Variations in nutrition ; causes. 

Relation to nervous influence. 

Section II. — Increased Nutrition — Hypertrophy - p. 299-302 

552-527 Varieties. /S'/m;?ie hypertrophy; of muscles. Examples of interstitial texturos. 
628 Of epidermis ; varieties in skin diseases. Complex hypertrophy ; uterus ; 

529 breasts ; brain ; follicles ; bursse, &c. Liver and spleen. Treatment of 
hypertrophy. 

Section III. — Diminished Nutrition — Atrophy - - P- 302-307 

530 General emaciation. Causes: divided into those which promote decay and 

those which prevent nutrition. Cause of emaciation in fevers. Vievfs of 

531 Dr. Hodgkin; Rokitansky. Drains from the body. Causes which prevent 

532 reparatory nutrition. When traced to its cause, general atrophy an im- 

533 portant sign. Partial atrophy from defective supply of blood. Examples. 

534 Treatment of atrophy, partial and general. 

Perverted Nutrition. 

535 Alterations in kind ; in texture. 

Section IV. — Induration and Softening - - - p. 307-311 

536, 537 Both may be independent of inflamm^ation. Nature of induration. Often ac- 
companied by transformation of tissues or interstitial deposit. Examples. 



XX CONTENTS. 

Paragrajjh, 

638 Softening. Specific causes. Common causes. Partial softening ; nature. Ex- 

639 aniples. Treatment of induration and softening, opposite but parallel. 
640, 541 Treatment of softening generally tonic and supporting. Action of nitric 

acid, &c. Specific causes. 

Section V. — Transformation of Textures ~ - P- 311-320 

542 Transformations general^ degenerations. Exceptions: skin and mucous mem- 

543 brane. Transformation of muscle. Four kinds of progressive degeneration : 
Fibrous, granular, fatty, and osseous, or calcareous. Fibrous, resembles 
fibrous tissue, but apt to degenerate farther. Muscles and parenchymatous 

544 organs exhibit this change, sometimes OTving to interstitial deposit. Granu- 
lar, a cacoplastic interstitial deposit or transformation ; invades morbid as 

545 well as natural fibrous tissues, and may degenerate farther. Fattg degenera- 
tion ; fat formed in the proper tissue of the parts, muscular, fibrous, and 
cellular; occtu's ujider the same circumstances as fibrous degeneration, but 
in more cachectic subjects. Fatty liver; appearance; subjects; cause. 
General fatty degeneration; subjects of it. Dr. George Johnson's views of 
Bright's kidney. Other examples of fatty transformation. Observations of 
Mr. Gulliver and Dr. Davy, Probably a chemical process like the formation 
of adipocire. Circumstances disposing to the general disorder ; as aflecting 
particular organs ; often preceded hy a cacoplastic deposit : always indicates 
a degradation of material. Analogy to vegetable matter. Efi"ects. Examples. 

546 Calcareous degenei'ation ; tissues most liable to it; a chemical process or 

petrifaction ; manner in which this occurs ; produced spontaneously in old 

547 age, or as a result of inflammation. Effects. Treatment of degenerations. 
]\Ieans of sustaining vital powers. Hygienic measures. Tonics. Alteratives, 
jNlineral waters, llemoval of local disorder. 

Treatment of fibrous and granular degeneration ; of fatty; of calcareous. 

Section VI. — Deposits in or upon Texture - - p. 320-343 

548 Definition of deposits. Nature. Division. 

549 i?(i7;/as^/c deposits. Cicatrices. Eeparation effected by three modes: union 

550 by fi^rst intention; adhesive inflammation; granulations. Dr. Carpenters 
account of the organization of cicatrices. Observations of Mr. Travers. 

551 Eeparation by blood, Pwemedial measures. 

553 Cacoplastic anci a])lastic deposits. Examples of the former : structure; causes, 

554 general and local. Cirrhosis. Grranular degeneration. Structure. Semi- 
-555 transparent, gray, and tough tubercle: a degraded kind of lymph, Connec- 

556 tion with other cacoplastic deposits. Tendency of cacoplastic deposits to 

contraction. Examples; elfects : intimate nature. Degeneration into aplastic, 

557, 558 the common tendency of tubercle, analogous to fibrous and granular and 

fatty degeneration. Form of tubercle. Causes. Microscopical and chemical 
character of granular tubercle. Opaque change indicates aplastic degenera- 

559 tion ; causes of this change. Primarj' aplastic deposits ; proof of degraded 

nutrition; yellow tubercle, maturation and softening: the converse of con- 
traction. Increase of fat in softened tubercle. Softening of tubercle attended 
bj^ the formation of a material offensive to the system. Changes of tubercle 

560,561 from adjoining textures. Quiescence of tubercle ; spontaneous changes, in- 

duration ; plastery and petrifactive change, absorption of ttiberculous matter. 

562 Causes of cacoplastic and aplastic deposits ; congestion ; chronic and asthenic 
inflammation; degraded plasma of the blood with defect of red particles. 

563 Seat of tubercles. Reasons of the liability of the lungs considered, Exter- 

564 nal or exciting causes of tubercles ; operation explained. 

565 Treatment of cacoplastic and aplastic deposits. Elements to be considered. 

566 J. Disordered condition of the blood audits causes. Remedial measures. 

2. Disordered distribution of the blood and its causes. Remedial and pre- 
ventive measures. 

567 3. Deposits already present; their efl'ccts and changes. Medicine of little 

eftect; why? Mercmy; alkalies; iodides; sarza; tonics. Solvents? caustic 

568 alkalies, acetic acid, naphtha, fixed oils. Cod-liver oil. Theory of its bene- 
ficial operation. Means which promote absorption. External countcr-ii-ri- 
tatiou. Nitric and hydrochloric acids, &c. 



CONTENTS. XXI 

Paragraph. ^^ 

Morbid Growths. 

569 Definition. Names and divisions. Analogous and heterologous, &c. 

Section YII. — Non-jialigxaxt Growths - - - P- 343-348 

570,571 Definition. Serous cysts. Distinguished from enlarged natural sacs. Encysted 

572 tumors. Hygroma. Hsematoma. Steatoma. Lipoma. Atheroma. Forma- 

573 tion of these. Contents. Complex cystiform tumors. Sarcoma. Fibrous 
Adipose. Chondroma. Erectile tumor. Dr. Hodgkin's view of the cysti- 

574 form origin of tumors. Pathological cause of morbid growths : altered Tital 

575 property of molecules. Hydatids. Proofs of separate yitality ; nature and 

576 origin; situations; death ; aplastic and fatty deposits around them. Echino- 
577, 578 coccus. Cysticercus. Distoma, Medical treatment of morbid growths, and 

their efl"ects. 

Section YIII. — Malignant Growths - - - P- 348-361 

579 Definition, Character of malignancy ; varies in degree, 

580 Carcinoma the generic term. Varieties traced to diJSTerent degi'ees of activity 

581 of cancerous matter. Some acute, some chronic. Elementary structure of 

582 cancer : cells ; forming fibres, &c. Disposition to grow at expense of nutri- 
tion. Parasitic nature ? germs or ova. Experiments of Langenbeck, Local 
origin of cancer as a modification of nutrition, Dr, Hodgkin's view, Prac- 

583 tical deductions from pathology of cancer. Mode of origin. Varieties of 
cancer explained by drfiference in quantity and activity of germs ; and activity 
of nutrition in adjoining textures. Scii'rhus is the chronic form. Symptoms ; 
tendencies. Open cancer : destructive efi"ects on part, and on whole frame. 

584 Pancreatic, mammary, lardaceous, and solanoid, intermediate forms of cancer. 

585 Mode of growth, Encephaloid cancer the acute variety ; in parts and sub- 

586 jects where nutrition is active. Cause of rapid growth of encephaloid dis- 
ease. Colloid cancer. The cancerous element in a separate form. Other 
varieties from form, &c. [Dr, Hughes Bennett's views.] 

587 Melanosis. Varieties, Peculiar black matter, its nature. 

588 ^/-m^TTze;?^ of malignant growths. Indications, 1, To extirpate them ; 2, To 
589, 590 retard their development ; 3. To counteract their efi"ects. Means of attempt- 
ing the fulfilment of these. 

Section IX. — Disorders of Mechanism ' - - p, 361, 362 

591 Changes in mechanism, elements of disease. Examples, 

592-595 Dilatation, Contraction, Rupture and laceration. Displacement and com- 

pression. Contortion. » 



CHAPTER V,— CLASSIFICATION, SYMPTOMS, AND DISTINCTION OF 

DISEASES. 
Section I. — Nosology ----- p, 362-365 

596, 597 Definition of special diseases. Methods of classification. 
598, 599 Symptomatic. Methods of Sauvage, CuUen, &c. Correct pathology the true 
600 foundation of natural classification. Definitions of disease with reference to 

pathology. 

Section II. — Semeiology and Diagnosis - - - p. 366-403 

601, 602 Definition of symptoms and signs. Physical signs. Examples. Those of dis- 
ease known by comparison with healthy standards. Standard of symmetry. 

603, 604 Anatomical standard. Physical signs explained by physical laws. Vital 

605, 606 symptoms. Called also functional and physiological, general and rational. 

607 Examples. Sources of symptoms. Pulse. Skin, Tongue, Stools. Urine. 

[Methods of pursuing the study of semeiology. Signs derived from the 
exterior of the body; from the head, neck, and face; the throat; thorax; 
abdomen; genital organs; extremities; nervous system ; respiratory system; 



XXll CONTENTS. 

Paragraph. 

circulatory system; digestive system; from tlie urine ; from the cutaneous 

609 exhalation; from animal heat.] Knowledge of pathology the best key to 

610 symptoms. Statistics a temporary substitute. Eespective value of physical 
signs and vital symptoms. Division and nomenclature of symptoms. 

611, 612 Diagnosis defined. How founded. Division into general and special. Diag- 

613, 614 nosis, illustrated by problems, and modes of solution. Need of every branch 

615 of medicine in diagnosis. The test of ability and knowledge. Methods of 

examination with regard to diagnosis, prognosis, and practice. 



617 
618 
619 




620 
621, 


622 


623, 


624 


625 




526 
627 
628 




629- 


-631 


632 




633, 


634 


635 
636- 


-638 



CHAPTER VL— PROGNOSIS.— FOREKNOWLEDGE OP RESULTS OP 

DISEASE. . - - p. 404-422 

Definitions. Prognosis empirical or rational. Empirical that of infant medicine. 
Prognostics of Hippocrates. Good and bad signs. Rational prognosis de- 
scribed and exemplified. Circumstances from which prognosis ma}^ be 
formed, 1, relating to the subject; 2, to the disease; 1, age of the subject; 
sex ; temperament ; previous diseases ; present diseases ; previous habits, 
condition of the patient at the time of the attack. 

2. Of the disease. The cause, situation, and nature, extent and progress ; the 
character of the symptoms. Good symptoms. Bad symptoms, signs of im- 
pediment to a vital function, and approach of one of the modes of death. 
Operation of all the modes of death on the blood, proved. Modes of death 
arranged in table. 

Death by Syncope. By spasm of the heart. Causes: by loss of irritability: 
causes, poisons, diseases : symptoms of approach. 
Death by Asthenia. Prom diseases : symptoms of approach. 
Death by Asphyxia. Distinctions. Symptoms. Causes. Varieties. 
Death by Coma. Causes: symptoms. Combined with excitement of the 

. medulla. How does coma cause death ? Medullary symptoms the most 
serious. 

Death by Paralysis. Injuries to the medulla, to the different nerves of respira- 
tion, to the diiferent nerves. Examples. Paralysis of spinal nerves with 
and without injury to the cord. With injury of cord itself, symptoms and 
fatal tendencies. 

Death by Necrapjnia. Explanation. Proofs of death of the blood. Mode of 
spreading death to other parts. External causes of necreemia. Vital resist- 
ance to its causes. JBymptoms. 

Mode of elimination of causes of necrsemia. Intrinsic causes of necr^mia. 

Symptoms of death by necrsemia. Slow deaths, more general. 



CHAPTER VIL— PROPHYLAXIS AND HYGIENICS. p. 423-458 

639, 640 Definitions. Prophylaxis connected with special pathology. Hygienics refer 
to means of resisting disease generally, and to means which maintain the 
general health. Subjects for consideration enumerated.' 

641,642 Food. Purposes of; essentials of wholesome food. Wheaten bread ; unfer- 
mented bread. Meat : use and abuse of cooking. Varieties of meat, and 
their constituents. Fish: broths and soups ; eggs and milk; cheese. Vege- 

643 tables. Choice of food and hour of meals. Breakfast and luncheon, dinner, 

644 tea, supper. Regularity in the hours of meals. Injury from long fasting. 

645 Clothing. Purposes. Provisions for alteration in the covering of the lower 

646 animals ; according to season, weather, and temperature. Materials of dress. 

647 Objects in selecting them. To protect from cold, from currents of air, from 

648 dampness and dryness. Cautions in changing winter for summer clothing. 
649, 650 Summer clothing. Silk vestments, electric influence. Cases requiring addi- 
651 tional warm clothing. Coverings for the head. Various cautions. 



CONTENTS. XXUl 

Paragraph. 

652 Air and tem]jerature. Beneficial effects of pure air; of cliange of air, seaside 

653 and inland. Trayeliing : high winds. Dry air; its ill effects ; modes of pre- 

654 venting them; causes ; soil; winds. The sirocco ; effects. Damp air. Effects; 
mode of operation. Cold and damp air ; effects. Causes of damp air ; 
winds, soil, dwellings. Marine humidity. Protective and counteractive 

655 means. Temperature ; average most healthy. Causes of the oppressiveness 
of heated rooms. Salutary influence of cool air. Cases requiring additional 

656 warmth. Mr. Jeffery's respirator. 

657 Ventilation. Modes of ventilating in winter and summer. Dr. Arnott's prin- 
658, 659 ciples and contrivances. Supply of warm air. Forces used in ventilation. 

Agents used for purifying air. 
660, 661 Bodily exercise. Beneficial effects of moderate exercise. Directions and 

662 cautions regarding exercise, according to age, strength, occupation, &c. 

Times for taking exercise. 
663, 664 Cautions as to amount and kinds of exercise. 

665 Mental occupation. Moderate and equal exercise of mental faculties beneficial. 

666, 667 Adaptation to age ; in infancy ; mental education and discipline : in youth ; 

668 in maturity. Body and mind to be equally exercised ; evil results of neglect- 

669 ing, and good effects of observing this rule. Variation of occupationinvigo- 
rates the mind. 

670 Sleep. Effects and nature of healthy sleep. Symptoms : gaping and yawning. 
671, 672 Circumstances which promote sleep : those which prevent or disturb it. 

673 Evil consequences of want of sleep. Directions to bad sleepers. Means of 
inducing sleep: Mr. Gardner's; the author's; Dr. Franklin's, &c. Reasons 

674 of their failure. Amount of sleep proper ; varies with age, sex, strength, 

675 occupation, &c. Sleep to be limited, especially in certain cases. 

676 Excretion. A proper subject for hygienic rules; depends on due activity of 

677 many functions. Intestinal excretion. Importance of punctuality and time 

678 for its evacuation. Vaiious aids ; in diet, exercise, by habitual aperients ; 

679 their safety and efficacy when needed. 

680 Urinary excretion ; its importance. Amount and quality varies with diet, 

exercise, &c. Cold water and other diuretic drinks. Propriety'- of timely 

681 but not too frequent evacuation. Excretions of the shin not fully known ; 

682 objects specified, promoted by various hygienic means, and specially by 
bathing, washing, and friction : operation and useful application of these. 

683 [General hygienic rules for the sick. Dry and well-ventilated apartments. Tem- 

perature of the sick room. Light. Fumigations. Bisk of m.oving patients. 

684 Cleanliness indispensable. Mode of changing the linen of patients. Auxiliary 

means to receive the excretions and prevent pressure. 

685 Food. Amount of nourishment necessary. Rule for its administration. In- 

judicious use of food. 

686 Removal of the excretions. 

687 Repose and quiet, 

688 Sleep. Manner of provoking it. 

689 The sensations. Emotions. Intellectual faculties. Conversation. Necessity 

of attention and sympathy to obtain the confidence of the patient. The fear 
of death. Propriety of communicating to patients their state. 

690 Hygiene of chronic diseases.] 



APPENDIX. 

Chemical pathology of gout and albuminuria. Additional facts proving the 
presence of lithic acid and urea in the blood, and their deficiency in the 
urine. Cure of albuminuria - - - - - p. 459 

Dr. Garrod's researches and theory on the causes and treatment of scurvy. 
Corroborative facts ------ p. 460 

Dr. Simpson's discovery of the use of chloroform vapor as an anesthetic agent: 
its mode of action ; cautions as to its employment - - p. 461 

The Study of General Pathology the proper Fouisidation op Practical 
Medicine (being a portion of an Introductory Lecture delivered in 1842) 

p. 403 



XXIV CONTENTS. 

State of practical medicine as a study and as an art. FaA^or sliown to empiri- 
cism by the public. Irksome and difficult character of the study of medicine 
as usually taught. Insufficiency of empirical and nosological medicine. Some 
knowledge of general pathology at length gained in practice. Need of gene- 
ral pathology in the study and practice of medicine. What is general patho- 
logy? Contributions from all departments of medical science, especially 
clinical medicine. General pathology the proper introduction to special 
pathology. Where principles fail, experience must be the sole guide. Noble 
nature and objects of medicine the best encouragements to its careful study. 



# 



PRINCIPLES OF MEDICINE 



EXPLANATION OF THE SUBJECTS OF THE WORK. 

1. The Principles, Elements, or Institutes of Medicine comprise 
those leading and general facts and doctrines regarding disease and its 
treatment, which are applicable, not to individual cases only, but to 
groups or classes of diseases. The same branch of medical knowledge 
is also designated by the term General Pathology and Therapeutics, 
to distinguish it from special pathology and therapeutics, or the theory 
and practice of medicine in relation to individual diseases. 

2. The principles of medicine may be deduced in part from a know- 
ledge of animal structure and function (anatomy and physiology), con- 
joined with an acquaintance with the agents which cause and remove 
disease; but chiefly they are derived from a generalization of facts 
observed in an extensive study of disease itself, and its eifects, in the 
living and in the dead body. But so far as they have been ascertained, 
they become more intelligible to the student if explained synthetically, 
by describing first the causes of disease, then their operation on the body, 
and lastly, the resulting changes in function or structure which consti- 
tute disease in its more elementary forms. 

3. Etiology, or a knowledge of the causes of disease, will intro- 
duce us to their effect — disease itself; the nature and constitution of 
which will then be considered under the head of pathogeny, or patho- 
logy PROPER. As this last subject is the chief one to be treated, it will 
occupy the greater part of the work, and it will be combined v/ith such 
an elementary view of the principles of treatment (general thera- 
peutics), as reason and experience may supply. 

4. A short general view will afterwards be given of the phenomena 
of disease (semeiology), the division and classification of disease (noso- 
logy), their distinction (diagnosis), their result (prognosis), and their 
prevention (prophylaxis and hygienics). 



definition of disease. 

5. The reader is supposed to be acquainted with anatomy and physi- 
ology ; without a knowledge of these, we cannot proceed even to a defi- 
3 



84 EXPLANATION OF THE 

nition of disease. Disease is known only by comparing it with the 
standard of health, which it is the object of anatomy and physiology to 
describe. 

Health consists in a natural and proper condition and proportion in 
the functions and structures of the several parts of which the body is 
composed. From physiology, we learn that these functions and struc- 
tures have to each other and to external agents certain relations, which 
are most conducive to their well-being and permanency; these constitute 
the condition of health. But the same knowledge also implies that func- 
tion and structure may be in states not conducive to their permanency 
and well-being ; states which disturb the due balance between the seve- 
ral properties or parts of the animal frame ; and these states are those 
of disease. For example, physiology, as well as experience, teaches us, 
that in health the digestion of food is easy and comfortable. But when, 
after food is taken, there are pain, uneasiness, sickness, eructation, flatu- 
lence, or the like, we know that the function of digestion is changed 
from the healthy standard — is diseased ; and if this diseased function 
continue long in spite of remedies which usually correct it, and if on 
examining the abdomen, we find at or near the epigastrium a hard tumor, 
which anatomy teaches us is not there in health, we know that there is 
also diseased structure. 

6. We find, then (§ 5), that there is disease of function, known by its 
deviation from a standard furnished by physiology ; and disease of struc- 
ture, which we recognize by a standard supplied by anatomy (§ 6). 
These varieties of disease may be, and very commonly are, combined : 
there is seldom structural disease without some disorder of function ; and 
in many instances functional disease is, or will be, accompanied by 
change of structure. 

7. Looking, then, to anatomy and physiology as standards, we may 
define disease to be, a changed condition or proportion of function or 
structure in one or more parts of the body. 

8. The standard of health is not, however, the same in all individuals; 
that which is health to one may be disease to another. Thus, if we in- 
stance individual functions : The healthy pulse in adults averages from 
70 to 80 ; yet there are some in whom 90 or 100 is a healthy pulse. 
Some persons fatten on a quantity of food on which others would starve. 
The animal functions, muscular strength and activity, nervous sensi- 
bility, and the sensorial powers, vary still more in different individuals, 
yet all within the limits of health ; and, what is health in one, would be 
decidedly morbid in another. Such unusual proportions of certain struc- 
tures or functions constitute varieties of temperament; and although they 
can scarcely be called morbid, yet they certainly give, as we shall after- 
wards see, a proclivity to disease. Thus a predominance of the func- 
tions of the nervous system, sensibility and excitability of the excito- 
motory nerves, constitutes the nervous temperament, which is compatible 
with perfect health, although it predisposes the individual to diseases of 
the nervous system. A preponderance of the nutritive functions renders 
a person stout and bulky, although in perfect health; but it carries with 
it a risk of exceeding the bounds of health, and of inducing plethora and 
obesity, which, as they interfere with the well-being and order of the 



SUBJECTS OF THE WORK. 35 

bodily functions, constitute disease. But short of these degrees which 
are morbid, the functions and structures of the body present, in healthy 
individuals, a considerable variety in energy and development. 

[All variations from regularity in the actions performed by living be- 
ings, constitute the phenomena of disease. The investigation of these 
phenomena, and the reduction of them to general laws, expressive of 
their conditions, is the object of Pathology. Here, as in the kindred 
science of Physiology, the study of all the conditions is requisite ; and 
hence we have to make ourselves acquainted, on the one hand, with the 
characters of all the external agents which can produce a deleterious 
effect upon the living body, whether their operation be mechanical, 
chemical, or vital, as well as the results of the suspension, partial or 
complete, of the conditions by which its healthy action is maintained. 
We have, too, to investigate the changes of structure which manifest 
themselves in the body itself, and the countless variety of secondary 
results which arise from any disturbance of its train of actions. The 
Pathologist sets out with endeavoring to determine the individual phe- 
nomena of diseased action, and when he has collected these in sufficient 
amount to serve as the basis of an induction, he attempts to ascertain 
the conditions common to all, and hence to arrive at their laws. The 
general principles of Pathology can only be founded on a knowledge of 
the elementary phenomena of disease. The ars onedendi, or the prac- 
tice of the healing art, is based on the 7'atio medendi, or its theory. 
Were the science of Pathology more perfect, the rules deduced from 
its general principles would be of easier application, and would require 
only correct observation of the circumstances which called for their 
employment. — C] 



CHAPTEK I. 

ETIOLOGY.— ON THE CAUSES OF DISEASE. 



SECTION I. 

NATURE AND DIVISION OF CAUSES. 

9. Causes of disease are those circuiDstances which essentially pre- 
cede it, and to the operation of which its occurrence is due. In many 
instances, these circumstances elude our observation. In many others, 
the true cause, if apparent, is combined with other antecedent circum- 
stances which have no share in producing the disease, and yet are liable 
to be mistaken for causes. These circumstances are to be sifted and 
the true cause discovered, only by the attentive observation of large 
numbers of cases, in which disease is produced. The non-essential cir- 
cumstances will then be found to be sometimes absent, and that which 
is always present may be fairly regarded as the cause. But this, as be- 
fore stated, sometimes eludes observation ; and both in this case and in 
elucidating the operation of circumstances supposed to act as causes, the 
most useful knowledge may be obtained from an investigation of the ul- 
timate nature of disease itself, which will often throw light on the cause 
which has induced it. Thus, it was long a matter of doubt whether the 
itch could be engendered from filth, as well as from contagion ; but 
since microscopic investigation has discovered the existence of the itch- 
mite, no doubt remains that this insect is the onlv essential cause of the 
disease. 

10. The causes or circumstances inducing disease may be mtrinsic, 
or existing within the body, independently of any obvious external in- 
fluence ; or they may be extrinsic, having their origin witlJout the body. 
As examples of intrinsic causes may be mentioned excess or defect of 
some function, as irritability, or of some constituent of the body, as the 
blood. Extrinsic causes are very numerous ; comprising all the external 
agencies which can operate on the body or mind, such as temperature, 
air, moisture, food, poisons, mechanical and chemical influences, sensual 
impressions, &c. &c. 

11. A great variety of agents and circumstances may thus act on the 
body so as to produce disease ; but, in most instances, there is not that 
uniform and constant relation between these as causes, and the diseases 



PROXIMATE AND REMOTE CAUSES OF DISEASE. 37 

as effects, wliicb we rolglit expect from the analogy of causation in the 
simpler sciences. In chemistry or in mechanics, effects certainly and 
uniformly follow causes ; in physiology or pathology, no doubt, effects 
also ensue ; but whether these effects shall be manifest as disease or not, 
will depend on many circumstances, of which we often cannot take cog- 
nizance. It is true that when the causes resemble and act like those of 
physics or chemistry, their proper effects will not fail to ensue. Thus, 
a cutting instrument, a redhot iron, or a corrosive liquid, will not fail to 
produce disease, because its operation is so energetic as to overcome all 
vital properties by physical and chemical force, and disorder must fol- 
low. Further, certain poisons and other potent agents, which act on 
without destroying the vital properties of living parts, may also, if of 
sufficient strength, pretty constantly produce morbid effects. Thus, 
opium, taken internally, causes somnolency ; tartar emetic excites 
nausea and vomiting ; cantharides applied to the surface induces in- 
flammation, &c. 

12. But the common causes of disease are seldom of this decided and 
positive character; they are often present without disease ensuing ; and 
they are known to be causes only because disease is observed to ensue 
in a greater number of cases when they are present than when they are 
absent. Thus, improper food is a cause of indigestion, and exposure to 
cold is a cause of catarrh; yet many persons eat unwholesome food 
without suffering from indigestion, and many are exposed to cold with- 
out "takins^ cold." But those who do suffer from indio-estion ob- 
serve that they do so more after taking improper food ; and those who 
are affected with catarrh can often trace it to exposure to cold. The 
reason of this uncertainty of action is chiefly in various powers by which 
the body resists the morbific influence ; which powers vary much under 
different circumstances. The failure or irregular operation of this power 
constitutes one predisposition to disease. 

13. Causes of disease were formerly divided into remote and j^'^^oxi- 
mate ; the remote include both the predisposing and the exciting causes, 
the only circumstances now considered as causes. They were called 
remote, not because they are distant or not in the body, but because 
they are not, like the proximate cause, a constant and present part of 
the disease. The term proximate cause, was used by Cullen (after 
Gaubius) to represent the pathological condition, or essential bodily 
change, on which the symptoms depend ; and it was called a cause of 
the disease, because diseases were by him defined to be an assemblage 
of symptoms. But this essential bodily change is rather a part of the 
disease than a cause, and must be considered under the head oi p)at}io- 
logy. Discarding, then, the term proximate cause, we have only to 
consider the predisponent and exciting causes. 

14. The co-operation of both these kinds of causes is generally neces- 
sary to produce disease. A number of persons are exposed to cold : one 
gets a sore throat ; another, a pleurisy ; another, a diarrhoea ; another, 
some form of rheumatism; and a fifth escapes without any disease. All 
five were exposed to the same cause, yet it acted differently on all. The 
first four were predisposed to the disease, which attacked them as soon 
as it was excited by the cold. The fifth had no predisposition ; the 



38 ETIOLOGY — CAUSES OF DISEASE. 

exciting cause was therefore powerless ; it was insufficient without the 
predisposing cause ; as in the other cases, the predisposition was insuffi- 
cient until the exciting cause, the cold, was applied. 

15. In some cases, however, where sufficiently strong, what is in a 
smaller degree a predisposition, in a greater degree constitutes a sole 
cause of disease (§ 11) ; thus a person with a very weak stomach always 
has indigestion, whether an exciting cause be applied or not. So like- 
w^ise exciting causes, if sufficiently strong, may produce disease without 
predisposition ; thus a person not predisposed to indigestion may be 
pretty sure to earn it, if he take a sufficient quantity of fat, raw cucum- 
ber, pickled salmon, or any such indigestible matter. Take another 
example. A healthy person living in a marshy district may not get an 
ague, until he becomes debilitated by any cause, such as cold, or fa- 
tigue ; then the poison will act. But without his being thus weakened, 
if the exciting cause be made stronger by his sleeping on the very 
marshy ground itself, then the poison may act without predisposition, 
and the ague begins (§ 12). 

16. The consideration of these facts throws some light on the nature 
of many predisponent causes. There is, in organized beings, a certain 
conservative power which opposes the operation of noxious agents, and 
labors to expel them when they are introduced. The existence of this 
power has long been recognized, and in former days it was impersonated. 
It was the archseus of Van Helmont ; the anima of Stahl ; the vis medica- 
trix naturas of Cullen. But without supposing it to be aught distinct 
from the ordinary attributes of living matter, we see its frequent opera- 
tion in the common performance of excretion ; in the careful manner 
in which the noxious products of the body, and offending substances in 
food, are ejected from the system ; in the flow of tears to wash a grain 
of dust from the eye ; in the act of sneezing and coughing to discharge 
irritating matters from the air-passages ; and in the slower, more com- 
plicated, but not less obvious example of inflammation, effusion of lymph, 
and suppuration, by which a thorn or other extraneous object is removed 
from the flesh. 

17. This vis conservatrix (§ 16) is alive to the exciting causes of dis- 
ease ; and in persons in full health, it is generally competent to resist 
them. How it resists them will depend on what they are. For in- 
stance : Is cold the cause ? This throws the blood inwardly ; which, 
by increasing the internal secretions, and exciting the heart to^ increased 
action, establishes a calorific process, which removes the cold. Is the 
cause improper food? The preserving power operates by discharging 
this speedily by vomiting or by stool. Is it a malarious or contagious 
poison ? It is carried off by an increase of some of the secretions. But 
if this resisting power (§ 16) be weakened, locally or generally, or if 
the exciting cause be too strong for it, then the cause acts, and disease 
begins (§ 15). 

18. In the cases hitherto noticed, predisponent causes consist in ab- 
sence or deficiency of power (§ 16), rather than the existence of any- 
thing positive ; but sometimes predispositions depend on something 
positively wrong in function or structure, which alone may scarcely 



PREDISPOSING CAUSES OF DISEASE. 39 

amount to disease ; and this error may be congenital, or hereditary, or 
acquired from previous disease. 

19. It must be observed that predisponent causes operate chiefly 
through the constitution, or some of its powers ; hence they are often 
called constitiitio7ial or internal causes, in contradistinction to the excit- 
ing causes, which are more commonly external. But these terms are 
objectionable, because not always applicable. Sometimes the term pre- 
disposiiig is also inappropriate, as in the following instance : Several 
persons are exposed to a malarious or infectious poison ; some of these 
afterwards suffer much from fatigue or privation ; they then begin to 
show the effects of the poison ; others, who have not suffered this second 
trial, escape unhurt. The poison has entered the system of both ; the 
last resist its influence ; the subsequent weakening reduces the powers 
of resistance in the first class, and exposes the system to the exciting 
cause ; but, occurring after, it cannot be said to predispose. Hence, un- 
der such circumstances, the fatigue or privation is called the determining 
cause. 

The frequent inapplicability of the terms under which the causes of 
disease are classified, suggests the truth that these divisions of causes 
are rather conventional and convenient, than natural and philosophical. 
The true, simple view of causes, is that they are circumstances inducing 
disease. If strong, one such may be sufficient ; if weak, two, three, or 
more may be required to operate together, or in succession, before that 
change of function or structure, which constitutes disease (§8), ensues. 
Which of these several circumstances respectively disposes, excites, or 
determines, and would therefore come under the divisions that I have 
endeavored to explain, will often be very difficult to decide. 



SECTION 11. 

PREDISPOSING CAUSES OF DISEASE. 

20. Predisposing causes of disease commonly consist of various cir- 
cumstances which influence the functions or structures of the body in an 
unfavorable manner, yet short of actual disease. It will be useful to 
illustrate them by examples, which I will group under the following 
heads. 

I. Debilitating Influences. 
II. Excitement. 

III. Previous Disease. 

IV. Present Disease. 

V. Hereditary Constitution. 
VI. Temperament. 
VII. Age. . 
VIII. Sex. 

IX. Occupation. 
I. Debilitating Causes of Predisposition are' the most numerous 



40 * PREDISPOSING CAUSES OF DISEASE. 

of any. So we might expect, from the fact that constitutional strength 
generally implies power of resisting disease (§§ 16, 17). The weak- 
ness Avhich renders the body liable to disease is that especially which 
enfeebles the heart, and impairs the tone of the arteries ; it is often 
accompanied with an unusual susceptibility of the nervous system, 
which increases the liability of the body to suffer. The following are 
the chief of this class. 

21 («). Imperfect nour{sh7nent, from defect either in the quantity or 
quality of the food, or from incapacity of the digestive powers. This in 
itself may cause many diseases, particularly of digestion and nutrition ; 
but it also weakens the power to resist cold, and produces a liability to 
low fevers and inflammations, epidemic and contagious disorders. Thus 
the susceptibility of the body to cold and to infection, when fasting, is 
generally acknowledged ; and the rapid propagation of infectious dis- 
eases among an ill-fed population, such as the poor Irish, is too well 
known. 

22 (5). Imjmre air. — The injurious effects of this are apparent in 
the pallid, cachectic complexion of the inhabitants of crowded cities, 
even those who live well and regularly. How do they contrast with 
the ruddy countenances of the hardy and coarsely-fed mountaineer ! So 
do they also in their liability to diseases, particularly to those of the 
organs of respiration, circulation, and nutrition. 

[One of the most fertile sources of infantile disease, is a want of a 
due supply of pure and wholesome air; the effects of which are sure to 
manifest themselves, though often obscurely, and at a remote period. It 
'is physiologically impossible for human beings to grow up in a sound 
and healthy state of body and mind, in the midst of a close, ill-ventilated 
atmosphere. Those that are least able to resist its baneful influences, 
are carried off by the diseases of infancy and childhood; and those 
whose native vigor of constitution enables them to struggle through 
these, become the victims, in later years, of diseases which cut short 
their term of life, or deprive them of a large portion of that enjoy- 
ment which health alone can bring. This statement is supported by 
facts. A recent visitor to the Island of St. Kilda, the most northern 
of the Hebrides, states that eight out of every ten children, die between 
the eighth and twelfth day of their existence ; in consequence of which 
terrible mortality the population of the island is diminishing, rather 
than increasing. This is due not to anything injurious or pernicious 
in the atmosphere of the island ; for " its air is good and the water ex- 
cellent ; but to the filth in which the inhabitants live, and the noxious 
effluvia which pervade their houses." The huts are small, low-roofed, 
and without windows, and are used during winter as stores for the col- 
lection of manure, which is carefully laid out upon the floor, and trod- 
den under foot, till it accumulates to the depth of several feet. The 
clergyman, who lives exactly as those around him do, except as regards 
the condition of his house, has reared a family of four children, all of 
whom are well and healthy ; whereas, according to the average mortali- 
ty around him, at least three out of four would have been dead within 
the first fortnight. At the end of the last century, in the Dublin 
Foundling Hospital, during a space of 21 years, ending 1796, out of 



DEBILITATING INFLUENCES. • 41 

10,272 sick cliildren, sent to the infirmary, only 45 recovered. Defi- 
cient ventilation, from the crowding of the wards, was an efficient agent 
in this fearful result.^ — C] 

23 {e). Excessive exertion of hody or mind. — Exercise is beneficial 
to both body and mind ; but when in degree or continuance it exceeds 
what the strength can bear, or rest can recruit, the animal functions are 
exhausted, and lose their balance ; muscular tone is impaired, nervous 
excitability takes the place of strength, the circulation fails, congestions 
ensue, the blood is not properly purified, and the various organs are on 
the brink of disease. It is thus that the fatigued mind or body is pecu- 
liarly prone to suffer from causes of disease. Want of sleep has simi- 
lar effects ; and w^hen the body is extremely exhausted, even sleep, 
which is nature's best restorer, is disturbed by the imperfect perform- 
ance of circulation and respiration in the excess of weakness ; hence a 
liability to insomnia and nervous excitement from exhaustion. 

24 id). Want of exercise and sedentary habits generally^ form an- 
other extreme which favors the production of disease. The healthy 
vigor of all the functions of the body and mind is best maintained by 
their equal and moderate exercise ; and the torpor of inactivity renders 
them incapable of resisting the causes of disease. The muscular func- 
tion, and with it the circulation of the blood, is the first to suffer; hence 
first sluggish movements, and ultimately weakness of the heart and 
other muscles. The defective circulation is felt most at parts at a distance 
from the heart, hence cold extremities, dry skin, congested liver, with 
its frequent concomitants, hemorrhoids, torpid bowels, and indigestion ; 
whilst the heart itself and the organs near it may be oppressed and in- 
jured by the load of blood in them, especially if the subject is plethoric; 
hence palpitation, dyspnoea, headache, vertigo, somnolency, dulness of 
the senses, &c. &c. In nervous subjects, convulsive affections may be 
promoted by the same inequality of circulation. The respiration being 
little exercised, the task of decarbonizing the blood is imperfectly per- 
formed, or falls more on the liver; hence the accumulation of fat in the 
textures, and the occurrence of bilious derangements. From this state- 
ment it is obvious that sedentary habits, where extreme, may be equi- 
valent to produce disease, and where existing in less degree, they pro- 
mote its occurrence from other causes, such as irregularities of diet, 
exposure to cold, violent exertion, &c. From such combination of in- 
fluences arise various disorders of the digestive organs, heart, lungs, 
and brain, catarrhs, gout, rheumatism, calculous affections, diseases of 
the skin, &c. 

25 (e). Long -continued heat. — The debilitating effects of this agent 
are exemplified in warm climates and seasons. Under its influence, 
the muscles, and with them the heart and arteries, lose power and tone ; 
the textures become relaxed ; perspiration is profuse ; and internal or- 
gans, especially the liver, are too much stimulated by blood which has 
lost more than usual of its water, and less of its hydro-carbon. Hence 
the disposition to bilious and liver complaints, dysentery and cholera. 
[The action of heat is debilitating from the losses the economy sustains 

' Carpenter's Animal Physiology, pp. 3, 4. 



42 • PREDISPOSING CAUSES OF DISEASE. 

from tlie undue cutaneous secretions, and from over-stimulation of the 
nervous system. This debilitating action of heat is increased when 
combined with moisture. Diseases of the gastro-intestinal mucous 
membranes are more especially developed. Under the influence of these 
two agents combined — heat and moisture — there is a marked tendency 
in diseases to assume a typhoid or adynamic form. — C] Overheated 
rooms and excessive clothing likewise predispose to disease by their 
weakening and relaxing influence. [Warm clothing is a source of dis- 
ease, and very often of the same diseases which originate in an expos- 
ure to cold. Overheated sitting and sleeping apartments, warm soft 
beds and bedclothing, relax and weaken the frame, disposing to dis- 
orders of the renal, urinary, and generative organs, and render the 
system generally much more impressible to external injurious influences. 
A predisposition is thus induced not only to catarrhs, inflammations, 
afi'ections of the lungs, and rheumatism, but to irregularity in the men- 
strual discharge. It has been remarked that the females of Holland, 
who generally use very warm clothing, warm apartments, warm beds, 
and footstoves, are subject to excessive menstruation and leucorrhoea. 
— C] It may be remarked that most of the diseases of hot climates 
and seasons occur rather at the termination of the heat than during its 
steady prevalence, and that therefore it predisposes to, rather than ex- 
cites, the disease, which is the immediate eff'ect of cold, or of irregular- 
ity of diet, or of malaria. Thus the bilious cholera of this country 
occurs chiefly in the early autumn, when the cool of the evening forms 
a contrast with the heat of the day. The chill suddenly arrests the 
perspiration, and throwing the blood inwardl}^, oppresses internal or- 
gans, especially the liver, whose vital energies have been exhausted by 
the influence of the previous heat ; hence coldness of the surface, and 
congestion of the liver and portal system, ending in flux, cholera, diar- 
rhoea, dysentery, &c. 

26 (/). Long-contmued cold. — The experiments of Chossat and 
others clearly prove cold to be a direct sedative, capable of reducing all 
the vital properties. Cold applied suddenly and for a short time, in- 
vigorates, because it is followed by a healthy reaction, in which the 
vital properties are exercised and exalted. But when long continued, 
its own sedative and debilitating efi'ects are permanent; it weakens the 
circulation, especially that of the surface, causes internal congestions, 
and directly lowers all the vital energies. Hence the most malignant 
forms of epidemic fever in this country are observed to prevail towards 
the close of very severe winters ; and all diseases may then assume a 
typhoid type. This is observed chiefly among the lower orders, whose 
means do not enable them to protect themselves sufficiently against the 
inclemencies of the season. We have before adverted to the striking 
manner in which cold disposes the body to sufier from malaria. 

27 [g). Habitual intemperance with intoxicating liquors. — There is 
probably, in this country, no source of disease more fertile than this. 
Besides many which it excites, it predisposes the body to attacks of 
fever, erysipelas, dysentery, cholera, dropsy, rheumatic and urinary 
diseases ; and if it do not increase the proneness to inflammatory dis- 
orders, the habit of intemperance certainly disposes them to unfavor- 



DEBILITATING IXFLUEXCES. 43 

able terminations, and causes many a yictim to sink after accidents and 
operations, -whicli would be comparatively trifling in a sober subject. 
Nor can we wonder at tbe pernicious effects of this kind of excess, when 
we consider the weakened state of function and structure which stimulat- 
ing drinks induce, especially in the organs which they most directly 
affect — the stomach, the liver, the kidneys, the heart, and the brain. 
We shall soon have to explain how such an unsound state of these or- 
gans peculiarly impairs the powers of the body to resist or throw off 
disease (§ 17). 

28 (Ji). Depressing passions of the mind, such as fear, grief, and de- 
spondency. — Many are the instances in which numbers, as well as indi- 
viduals, have escaped a prevalent disease, until depressed by some un- 
happy event or apprehension, and then they have fallen victims. Such 
was instanced in the ill-fated Walcheren expedition, and in many pass- 
ages in the history of armies in pestilential countries. A defeat, a fail- 
ure, or even bad news, made many succumb to the pestilence who had 
before escaped. It is a common remark, that when a contagious or 
epidemic disease prevails, those who take most precautions frequently 
suffer, because they are timid and fearful, whilst the stout-hearted and 
reckless are unscathed. [AYhen the mental energies are depressed by 
fear, grief, anxiety, disappointment, &c., the powers of life are less able 
to oppose the debilitating causes of disease; and individuals, singly, or 
collectively, are, under such circumstances, especially liable to those 
disorders which are of a general or specific origin, as fevers, &c. There 
is nothing which more certainly predisposes the system to the opera- 
tion of the exciting causes of fever, than the fear of being attacked by 
it. On the contrary, when the mind is elevated by success, hope, and 
confidence, or other exciting passions, depressing causes make little or 
no impression upon the constitution, and individuals thus circumstanced 
almost always escape from diseases which readily invade the fearful, the 
dejected, and the disappointed. Indulgence of temper and passion not 
only predispose to disease, but frequently excite it, in the nervous, irrit- 
able, and sanguine temperament. Diseases of the heart, brain, liver, 
stomach, and bowels often originate in these sources. Uncontrolled 
passions of every description occasion a host of functional and structu- 
ral disorders of the great viscera, whilst moderation of all the appetites, 
an equable state of mind, and the moderate excitement accompanying a 
well-regulated application to business or study, are among the best 
means of resisting the impression of injurious agents. — C] 

29 (z). Excessive and repeated evacuations, either of the Mood or of 
some secretion. — The weakening effect of a large loss of blood needs no 
explanation ; but the injurious influence of habitual losses or drains, if 
there be more than the system can repair, is still greater ; for the func- 
tions then become depraved as well as depressed, a state of cachexia as 
well as anaemia is induced, and a little cause may suffice to determine 
many states of disease. Various hemorrhages and discharges, menor- 
rhagia, diarrhoea, leucorrhoea, and other fluxes, if in excess, reduce the 
powers of life and the capacity to resist disease. No secretion, how- 
ever, weakens so much or so irreparably, when in excess, as that of 
semen. In many of the lower tribes of animals, the males live till they 



44 PREDISPOSING CAUSES OF DISEASE. 

copulate, and then die ; the reproduction of the species is at the expense 
of the individuaL That our species is not wholly exempt from this law 
of organized nature, is apparent from the fact that immoderate venery 
is known to produce extreme debility and premature decay, and to dis- 
pose the body and mind to various diseases. [Excessive sexual indulg- 
ence is a frequent predisposing cause of many diseases. Pulmonary 
and cardiac disorders, epilepsy, mania, and other disordered manifesta- 
tions of mind, not unfrequently occur, from the condition of the system 
induced by the abuse of this appetite. It also leads to other maladies 
by depressing the vital energies of the frame, and rendering it more 
assailable to the common exciting causes of disease. — C] 

30 (y). Previous debilitating diseases. — It is well known that the 
body is unusually liable to disorder during convalescence from serious 
maladies. It is weak in all its powers ; whilst the nervous system often 
obtaining the ascendency which is common in states of weakness, renders 
the body unusually susceptible (§ 23) ; and improper food, exertion, ex- 
citement, or exposure to cold, may readily produce the former or some 
new complaint. Hence convalescence from a severe disease is a con- 
dition of health that requires peculiar care. The functions are just 
resuming their balance, and have neither the vigor of action, nor the 
power of resistance which is the attribute of robust health. The dis- 
eases which leave the body most liable to derangement are those ending 
in exhaustion, as continued fevers and protracted and severe inflamma- 
tions. 

31. II. Hitherto we have considered only those circumstances which 
predispose to disease by their weakening influences (§§ 16, 17, 20). 
There are others, of a somewhat opposite character, which favor the 
production of disease by a state of excitement- or activity. Thus 
full living, without an adequate amount of exercise, may bring the 
circulation and other functions up to a high-pressure degree of activity 
without producing disease ; in fact, there is a redundancy of health ; 
and there is more than usual capability of resisting those causes of dis- 
ease which operate by depression, such as cold, malaria, infection, &c. 
But there is a predisposition to sufi'er from causes of additional excite- 
ment ; thus irritants applied, more readily induce inflammation ; violent 
exertion may cause hemorrhages ; and in any organ the operation of a 
stimulus may heighten the actions to a pitch that is morbid (§§ 5-8). 
So, also, unusual vascular activity in a part, when insufficient to produce 
disease, renders the part more liable to sufl'er from external causes. 
Thus the determination of blood to the uterus and mammas at certain 
periods, renders them liable to disease at those times. Violent exertion 
makes the muscles or their fasciae peculiarly liable to rheumatic inflam- 
mation from the subsequent action of cold and damp. Excessive in- 
dulgence in a stimulant diuretic beverage, such as punch, renders the 
kidneys liable to inflammation or congestion on exposure to cold. In- 
flammation or irritation of the intestines is not a common efl"ect of cold, 
except when these viscera are under the exciting influence of a purgative. 
The brain, if previously over-active from hard study, may be excited 
into inflammation by alcoholic stimulus or strong moral emotion. 

82. III. Proclivity to disease is not unfrequently caused by previous 



PRESENT DISEASE. 45 

DISEASE, independently of the weakening influence before noticed (§ 30). 
This is particularly the case with some inflammatory and nervous dis- 
orders. Thus, a child who has once had croup is very liable to its re- 
currence. One attack of enteritis frequently predisposes to its recur- 
rence. Convulsive disorders, such as chorea, hysteria, and epilepsy, 
are extremely apt to recur ; and the longer they have existed, the more 
difficult are they to remove, and the more ready are they to reappear 
on the application of any exciting cause. This is what may be called 
a habit of disease, which is most important to prevent. There can be 
little doubt that the previous attack in all such cases leaves some change 
of structure or function (§ 18), which constitutes the predisposition, 
although this change may elude our means of detection. 

33. Under this head we may arrange many constitutional predisposi- 
tions to disease which are to be ascribed, not to a previous attack, but 
to the persistence in the system of a cause of that attack. Rheuma- 
tism, gout, gravel, many cutaneous diseases, dropsy, jaundice, and many 
others, may be quoted as examples. A person who has once suff"ered 
from any of these is very liable to a recurrence on the application of an 
exciting cause ; and this is because, although free from the first attack, 
he may not be free from some functional or structural imperfection 
(§ 18) which was the predisponent to that attack, and which may again 
be brought into operation by the addition of an exciting cause. In 
most of these cases, the constitutional defect is in some of the processes 
of assimilation or excretion, this defect being generally functional, but 
in some cases it is also attended with change of structure, especially in 
the great eliminating organs, the liver and the kidneys. AYhen the 
tendency to the diseases under notice is acquired, it may be often traced 
to causes which peculiarly afl"ect these organs, such as intemperance or 
irregularities of diet, sedentary habits, and scarlet fever. 

Nor can we separate from this class of constitutional causes (§ 32) the 
predispositions to many structural diseases, such as tuberculous and ma- 
lignant formations. Where such have once appeared, there is a tend- 
ency to the production of more, although this tendency may be latent 
until brought into activity by an exciting cause. In the following pages 
many arguments will be found in favor of the view that the disposition 
to these diseases is connected with errors in the functions of assimila- 
tion and excretion. 

34. TV. Disease already existing in the body, even when itself 
latent, often predisposes to other disorders, independently of its weak- 
ening eff"ect (§ 20). Thus, tubercles and other tumors, structural lesions 
of the heart and other organs, often induce irritations or obstructions of 
bloodvessels, which, if not themselves causing open disease, render them 
ripe for disorder from other causes. Thus, a person on the occasion 
of violent bodily or vocal exertion, is seized with profuse spitting of 
blood, which causes his death ; on opening the body many tubercles are 
found in the lungs, although there had been no obvious symptoms of 
their existence before the violent effort. Again, disease of the heart, 
causing accumulation in the veins, often leads to congestion of the 
lungs and liver ; and it may only require the addition of an exciting 



46 PREDISPOSINa CAUSES OF DISEASE. 

cause, sucli as sudden exertion, or an excess in diet, to bring about an 
attack of asthma or jaundice. These are mere instances of causes 
coming into operation by accumulation. Granular disease of the kid- 
neys, which impairs their excreting power, renders the body more liable 
to suffer from infectious and other poisons, and from other exciting 
causes of disease. 

35. The predisposing causes hitherto considered, may be called acci- 
dental or acquired. There are others which are born with the individual; 
and others which arise from circumstances of age or growth. All these 
may be supposed to depend on something defective or ill-balanced in the 
organization (§ 18), which is insufficient to manifest itself until wrought 
upon by an external exciting cause. 

36. Y. Of the predispositions born with the individual, the most gene- 
rally acknowledged, is hereditary tendency to disease. It is well 
known that scrofula, gout, rheumatism, epilepsy, mania, asthma, blind- 
ness, and deafness, run in families. That this depends on individual 
peculiarities transmitted from parents to offspring, appears from the fact 
that all children do not partake, or not alike, of the disposition. [Thus 
it has been observed that in constitutional syphilis, a first child, born of 
parents, one of whom has been infected, may be tainted with the vene- 
real poison, whilst the second would be perfectly healthy, a third would 
be diseased, and a fourth sound ; thus alternating, as it were. Children 
born of gouty parents have escaped entirely the disease, but have trans- 
mitted it to their offspring, who have suffered from well-marked fits of 
podagra. — C.J Nay, sometimes a whole generation is passed over, and 
the disease appears in a third. So, too, we see external organization, 
family likeness, differently stamped on different children of the same 
family. [The influence of hereditary transmission is proved by nume- 
rous and positive facts ; indeed, peculiarities of configuration or feature 
are not more decidedly transmitted from the parent to the offspring, than 
constitutional taint, and certain pathological conditions. It is not sim- 
ply the influence of temperament, which, endowed with the same pecu- 
liarities, tends to produce the same disease, but a settled, inherent 
disposition to such, or such pathological development, which may be 
found, even when the resemblance does not exist. Under this influence, 
the disorder may go on, being propagated from one generation to another, 
or it may stop short at one. But in the latter instance, it seems neces- 
sary that this influence should be exercised in a regular, invariable, and 
general manner ; and in its expression great variety has been observed. 
Sex in some families would seem to modify the hereditary tendency, the 
females being attacked with one form of disease, and the males with an- 
other not analogous. This twofold effect of hereditary efficiency in the 
same family, would appear to be the result of a double influence, one 
disorder being derived from the mother, and the other from the father. 
In cases when the father and mother suffer under different constitutional 
disorders, a sort of crossing often seems to occur ; — the disorder of the 
father attacking the girls, whilst that of the mother appears in the males. 
Generally, the hereditary pathological tendencies of the mother are more 
readily transmissible than those of the father. — C] 



TEMPERAMENT. 47 

It must not be supposed that liereditary proclivity to disease com- 
mences at birth. In a few instances, it is congenital; but in the greater 
number it is developed by growth or some other circumstances in life. 
Gout, for example, is acknowledged to be hereditary. A parent has it 
in middle or advanced life ; his son does not get it until about the same 
period, sooner or later, according to whether he lives freely or not. 
Here is something transmitted from father to son, yet not manifest in 
the son for forty or fifty years. [It has been observed that diseases 
developed under the influence of hereditary predisposition, generally 
manifest themselves at an earlier age than that at which the same 
affection is ordinarily developed, independently of this predisponent 
cause. 

There are other instances, and very curious and interesting they are, 
in which the children of a family succumb to a disorder of which the pa- 
rents have never exhibited any traces, when subsecjuently the father, or 
mother, or both, are attacked, and thus the point of departure of the 
disorder, which had exercised a sort of anticipatory action on the off- 
spring, is disclosed. This variety of hereditary influence has been fre- 
quently observed, and especially with reference to insanity, in which 
disorder the children are not unfrequently attacked before the parent. 
A well -authenticated instance of the same manifestation in tubercular 
disease, has been recorded by a late authority. A young man of 19 
years of age, of fine constitution and great muscular development, after 
a violent physical exertion, was attacked with abundant haemoptysis, 
and shortly afterwards well-marked phthisis appeared, and he soon died. 
Neither his father nor mother had exhibited any tuberculous tendency, 
or a young sister, the only remaining child. When she reached 19 years 
of age, the young sister was attacked with pulmonary tubercular disease, 
and succumbed; and it was not for two years subsecjuently that the 
mother, 53 years old, presented the first symptoms of consumption, of 
which she soon died, thus exhibiting the existence of an hereditary in- 
fluence, whose effects had preceded the manifestation. — C] 

37. YL Frequently, but not essentially, connected with hereditary 
conformation, is the peculiarity of constitution called temperament, 
which certainly predisposes to particular diseases. Temperament con- 
sists in a predominance or defect of some function or set of functions 

(§9)- 

38. Thus the sanguine temperament implies an activity of the system 
which circulates red blood, and a rich proportion of red particles, 
manifest in the excitable pulse and flushing cheek of those of this 
temperament ; and further evinced in their quick movements and lively 
disposition. This temperament gives a disposition to inflammation, 
determination of blood, and active hemorrhage (§ 30). 

39. The phlegmatic or lymphatic temperament is the reverse of the 
sanguine ; it occurs in those with weak pulse and languid circulation, 
cold extremities, and pallid skin ; there is a deficiency of red blood and 
of vascular action and tone (§ 9), and the proclivity is to watery fluxes, 
dropsy, and other chronic affections. 

40. In the bilious or melancholic temperament, which is commonly 



48 PREDISPOSING CAUSES OF DISEASE. 

met with in persons of dark complexion and gloomy disposition, there 
is probably a defective action in some of the biliary or digestive organs, 
which are therefore the more liable to derangement (§ 9). 

41. The nervous temperament is externally manifest only by agita- 
tion or trepidation of manner ; it seems to depend on an excess or want 
of proportion of some properties of the nervous system (§ 9), and it pre- 
disposes to the disorders called nervous, such as hysteria, nervous pains, 
spasms, &c. These temperaments may be variously combined. 

The word diathesis is often used to express a particular morbid tend- 
ency ; thus we hear of the inflammatory diathesis, the scrofulous dia- 
thesis, &c. It is merely a term signifying disposition, without affording 
any clue to its true cause. 

42. YII. The last head of predisponent causes to be noticed, is AGE. 
The several changes in organization, as well as in external circumstance, 
which the animal frame undergoes at different periods of life, may natu- 
rally be expected to be attended with corresponding proclivities to 
disease. I proceed to enumerate a few of these, premising that some of 
the examples may be entitled to rank under the head of exciting causes 
of disease, as well as under that of predisposition. 

43 (a). [The organic conditions which obtain during infancy, as the 
general development of the system, the incessant and general acti\'ity of 
the nutritive forces, the predominance of the capillary circulation, give 
a special type to infantile pathology. Many diseases are so exceptional 
during infancy, that they may be said to form no part of its pathology ; 
whilst others, common indeed to all ages, offer at this period of life 
distinct and special characters, as pneumonia, for example. — C] In 
early infancy^ the low calorific power of the body disposes it to suffer 
from the bad effects of cold (§ 17), whence the tendency to visceral 
inflammations. The skin is particularly liable to various eruptions, in 
consequence of its tenderness, and the new and drying medium in which 
it is placed. The redness of new-born children is obviously the result 
of the action of the air ; it is often a vivid erythema, followed by des- 
quamation of the cuticle, and a yellow stain of the skin from extravasated 
hsematosin, which is erroneously thought to be a kind of jaundice. Stro- 
phulus and other papular eruptions often succeed, [with impetigo of the 
face and eczema of the scalp ; oedema of new-born children is peculiar to 
this period of life. — C] The comparatively virgin state of the aliment- 
ary canal at birth, renders it peculiarly susceptible of disorder ; and a 
similar trial may occur at the period of weaning ; hence arise diarrhoea, 
vomiting, colic, waterbrash, atrophy, and other ailments connected with 
disordered digestion, [with that form of enteritic disease called cholera 
infantum, the great desolator of the infantile population of our northern 
cities. — C] The brain, excited by the novelties of the external world, 
becomes rapidly developed, and in its increased activity and growth, is 
liable to various diseases (§ 30) ; hence the proclivity to hydrocephalus, 
convulsions, kc. The process of teething adds an irritation, which, by 
its influence on the nervous system, the bowels, and the air-passages, 
disposes them to disorder. [In early infancy, rachitism, with gangrene 
of the mouth (cancrum oris), the various forms of stomatitis and angina, 



AGE. 49 

as well as diphtheritic inflammation of the larynx and trachea, are fre- 
quently met with. — C] 

4-i [b). Childhood, or the age from infancy to puberty. — The functions 
most active are those which administer to growth ; the organs of diges- 
tion and assimilation are therefore obnoxious to disorder (§ 32) ; hence 
derangements of the stomach and bowels, worms, infantile remittent, &c. 
The activity of the nutritive function gives preponderance to the fibrin- 
ous or proteine constituent of the blood ; and inflammations which may 
occur are often attended with the eff'usion of much plastic or albuminous 
matter ; hence the products of croup, tubercle, mesenteric disease, &c. 
The natural mobility (or activity of the excito-motory system) of child- 
hood predisposes to chorea and kindred afl'ections (§ 30). [xit this 
epoch, too, tuberculous afl'ections of the bronchial ganglia, mesentery, 
peritoneum, and cerebral meninges, are of frequent occurrence, and 
present some peculiarities in their course and character, as do also some 
of the acute inflammations of the pulmonary organs, as bronchitis, pneu- 
monia, the latter generally occurring in the form called lobular. Stri- 
dulous or crowing laryngitis, and hooping-cough, with the eruptive 
fevers, as scarlatina, measles, and variola and its modificationSj are 
diseases of childhood. — C] 

45 (c). Puberty brings with it many morbid susceptibilities, chiefly 
in the female sex, in which the important function of menstruation is to 
be established. Many and serious are the evils that are liable to be pro- 
duced by external causes, which check the development of this function. 
So also, when established, this function has its nervous as well as its 
vascular relations ; and where it is irregular or disordered, a predis- 
position is given to many maladies afiecting the bloodvessels and their 
contents, the secreting organs, and the nervous system. 

[This is one of the most important periods of human existence, for 
during it the development of the organs of reproduction in the two 
sexes takes place, and the whole economy is brought to full perfection. 
The organs of respiration and of voice acquire their full growth and 
tone ; the muscles their due proportion ; and the cerebro-spinal system 
its complex and wonderful organization. The instinctive feelings and 
emotions reach their utmost limits; and many of them, especially those 
relating to the sexual organs, acquire an ascendency, and their indulg- 
ence becomes a cause of disease. From this source frequently spring 
impotence and the extinction of families ; the infliction, during after 
life, of many of the disorders which proceed from debility, and the ex- 
haustion of the nourishment and vital energy of the various organs ; 
innumerable nervous and convulsive maladies, as hysteria, epilepsy, 
neuralgia, chorea, melancholia, mania, idiocy, &c. ; diseases of the heart ; 
disorders of the digestive organs ; premature alopecia, and old age ; the 
formation of tubercles, and the production of pulmonary consumption ; 
and lastly, the transmission of weak and decrepit bodies and minds to 
the ofl*spring — scrofula, rickets, marasmus, hydrocephalus,- &c. The 
pathological tendencies of this age are especially characterized by ex- 
alted action. At the approach and commencement of puberty, the glands 
ular system is extremely prone to congestions and inflammations, par- 
ticularly the lymphatic ganglia of the neck and axilla. Tubercles are 
4 



Jaf) PREDISPOSING CAUSES OF DISEASE. 

rapidly developed in the lungs, and these organs are much disposed to 
acute and chronic inflammations of their substance and mucous surfaces; 
pulmonary hemorrhage replaces the epistaxis of childhood, and in females 
dysmenorrhoea, protracted menstruation, amenorrhoea, leucorrhoea, chlo- 
rosis, and hysteria appear. — C] 

46 [d). At the teimination of growtli^ there is another critical period. 
The cessation of that appropriation of nourishment for the increase of 
the body, that had hitherto been going on, may cause fulness of the 
vessels, and a disposition to hypertrophy, hemorrhage, and inflammation, 
in the more robust ; and in the cachectic, to morbid depositions, espe- 
cially of the tuberculous kind (§ 47). The same redundancy of the 
"vdvifying fluid in active circulation, gives that buoyancy of animal spirits 
and impulsive energy of feeling and strength, which are the character- 
istics of healthy youth ; yet this very exuberance of vital power, if not 
properly controlled and balanced, may constitute a tendency to disease; 
either directly, as where excitement rising beyond the limits of health 
borders on morbid action (§ 31) ; or indirectly, by leading to excessive 
exertion and subsequent exhaustion (§ 23). Youth is the age of sus- 
ceptibility to moral and physical impressions ; and therefore of liability 
to the disorders which these are capable of producing. 

47 (e). Adult age can hardly be said to predispose to any diseases, 
unless it be those arising out of mode of life. It is commonly a period 
of steadier health, because the functions are more evenly balanced ; but 
if the mode of life be unfavorable, bad habits are apt to become esta- 
blished, and by their continuance to induce disease. Thus gout, gravel, 
rheumatism, indigestion, and various other disorders, are apt to occur 
in middle life, because the predisposition to them is gradually engen- 
dered (§ 24) by some error in diet or regimen, too slight to excite dis- 
ease, but sufiicient by accumulation to dispose to it, on the addition of 
an exciting cause. [As the age of fifty is approached, the circulation 
becomes more languid, particularly that of the venous system ; hence 
the frequency of venous congestions and visceral obstructions, with the 
numerous train of disorders they occasion; as hemorrhoids, inflamma- 
tions of the great cavities, affections of the heart, apoplexy, paralysis, 
derangements of the stomach and bowels, gout, rheumatism, diseases 
of the urinary organs, hysteria, and uterine disorders, hypochondriasis, 
and mental alienation. It is asserted that ataxic phenomena are more 
frequent accompaniments of severe disease at this than at any other 
period. — C] 

As age advances, such habits aifect the organization, and accelerate 
those changes in the fabric, by which our existence is limited to a span 
of years. It would occupy too much space to enter into the details of 
all these changes, but some of the principal may be briefly noticed, as 
illustrating the weaknesses and liabilities of advanced age. 

48 (/). The changes which old age induces in the exterior of the 
body shows a failure of those functions which were active in youth. In- 
stead of muscles, fat, and integuments being nourished in the equal pro- 
portions that give beauty as well as strength to the form in mature life, 
the muscles become thin and sinewy ; fat becomes scanty, partial, or in 
excess ; the integuments are loose and wrinkled, or fat and flabby ; the 



ADULT AGE. 51 

joints stiffen, and the gait loses its firmness and uprightness. These 
changes in the textures of the body are attended, and probably induced, 
by altered proportions in the diiFerent parts of the vascular system. 
The pallid skin of age, contrasted with the ruddy blush of youth, proves 
the diminished development of the capillary bloodvessels, that great 
system which sustains the life and nutrition of the body ; hence much 
of the blood that in earlier age circulated on the surface, giving vigor 
and sensibility to all the external organs, and life and susceptibility to 
all outward relations, is now accumulated in the interior, and confines 
its vivifying and nutrient influence more to the internal functions and 
structures, thus tending to render the individual more isolated and 
selfish. But the blood thus abounding in the larger vessels is not equally 
distributed within them. The diminished capillaries intercept some of 
the force by which the blood is propelled through the arteries ; hence 
this fluid stagnates and accumulates in the veins, which become dis- 
tended and tortuous, whilst the arteries, exposed to the continued im- 
pulsive force from the heart, lose much of their elasticity, and become 
mere rigid tubes, causing the peculiar hardness of the senile pulse. The 
nutrition of the textures generally fails in activity, not in degree only, 
but in kind also, chemical transformations and deposits beginning to 
show themselves in the difi'erent structures. Thus fibrous and muscular 
tissues exhibit partial conversion into fatty matter, and osseous or petri- 
factive changes encroach on many structures of low organization; exhi- 
biting a tendency to degradation to the composition of mere vegetable 
and mineral matter. 

This altered proportion of the bloodvessels brings with it morbid 
tendencies, the nature of which will depend much on the great moving 
power, the heart ; now more than ever the prime agent in the circula- 
tion. If the heart be moderately strong, a fair balance may long be 
sustained ; although hemorrhoids, varicose veins, and such irregularities 
from local obstructions, may occur. If the heart be too strong (which 
is often the case after a life of much muscular . exertion), the small 
arteries may sufi'er from the unsoftened force of its pulses, particularly 
in the brain, and there is a liability to apoplexy or palsy ; and in 
mucous membranes, there is a disposition to active fluxes ; hence catarrh, 
asthma, and afi"ections of the urinary organs. The more vascular tex- 
tures, especially of internal organs, are over-nourished, and increase in 
size or weight. If the heart be weak or diseased, there will be imper- 
fect circulation and tendency to venous congestions, dropsical effusions, 
imperfect and disordered secretions, altered nutrition, and a general 
failure of all the functions which depend on a sufficient supply of arterial 
blood ; hence may arise diseases of the liver, stomach, kidneys, lungs, 
and in fact of any of the viscera ; in extreme cases, the lower extremities 
actually die for want of circulation. 

If, instead of the organs of circulation, we were to take the alimentary, 
the respiratory, or the urinary apparatus, we should here too find changes 
induced by age, which show the necessarily limited time that man's 
organization is intended to last. Old age is thus attended with increas- 
ing infirmities and liabilities to disease (§§ 16, 18). The very strength 
and activity which some functions retain, may, from their partiality, en- 



52 PREDISPOSINa CAUSES OF DISEASE. 

danger life ; and their gradual and more equal failure degrades the phy- 
sical and often the mental frame of man to a lower scale of existence, 
until he sinks into second childhood, dotage, and imbecility. 

49. YIII. Sex. — The liability which sex gives to the diseases of the 
respective generative organs, is too much of a truism to need mention. 
But the peculiarities of sex are not confined to these organs ; they ex- 
tend to many of the structures and functions of the body. 

The male sex is remarkable for the higher development of the muscu- 
lar and voluntary excito-motory system, with a corresponding strength 
of frame ; for the stronger impulses of the animal passions ; and for a 
greater endowment of the reasoning faculty. These respectively bring 
with them a liability to suffer from diseases of the muscles, limbs, joints, 
heart,, and great vessels ; from the evils contingent on undue indulgence 
of passion or appetite; and from disorders of the brain and its intellectual 
functions. 

In the female sex, the predominant bodily functions are the nutritive, 
the sensitive, and the involuntary excito-motory ; whilst the perceptive 
and instinctive faculties and moral emotions preponderate in the mind. 
Hence the greater proneness of females to changes in flesh and blood ; 
to disordered sensation, spasms, convulsive and other affections of the 
spinal system; and to the direct and indirect consequences of the indulg- 
ence or thwarting of instinctive and moral feelings. The predisposing 
influences of the menstrual function have been before noticed (§ 45) ; 
it may be now added, that its cessation favors the development of vari- 
ous diseases of function and structure, especially growths, simple and 
malignant. 

50. IX. Occupation comprises many circumstances already noticed 
under the heads of predisposing influences. Thus sedentary occupa- 
tions include want of' exercise (§ 24), and sometimes impure air (§ 22) ; 
laborious employments operate as excessive exertion (§ 23) ; other occu- 
pations may predispose to disease by the continued exposure to heat 
(§ 25) or cold (§ 26) which they occasion. Some employments require 
constrained postures, which, if insufficient to induce, may yet promote 
the occurrence of disease; thus engravers and watchmakers are liable to 
affections of the head from holding the head low; shoemakers and tailors 
are subject to disorders of the stomach from their stooping forward at 
their work. In many other instances, occupations induce disease rather 
by exposing the individuals to the exciting causes, than by inducing a 
predisposition ^ but, as before remarked, the very circumstances, which 
in great intensity suffice to excite disease, in a lower degree may only 
induce a disposition to derangement. Thus the slow introduction of lead 
into the system, occurring in the occupations of painting, plumbing, 
card-enamelling, and printing, may not cause colic until cold or irregu- 
larity of diet becomes an additional or exciting cause. The same remark 
will apply to dry grinding, needle-pointing, leather-dressing, and other 
unhealthy occupations. An important element in the influence which 
employments have in causing disease, is the time during which they are 
pursued ; thus an occupation, not in itself unhealthy, may become so 



COGNIZABLE AGENTS. 53 

when continued too many hours in the day ; and a work which is attended 
with risk, may be often safely undertaken for short periods with a due 
amount of relaxation or diversion to another pursuit. By attention to 
this point, the injurious influences of occupations may be much less- 
ened. 



SECTION III. 

EXCITING CAUSES OF DISEASE., 

51. We now pass to the consideration of exciting or occasional causes 
of disease, or those circumstances and agents which, operating on the 
body, especially when predisposed (§ 14), may excite disease in it. It 
has been stated before (§§ 11, 15), that certain powerful agents, such as 
irritants or. poisons, pretty surely cause disease, independently of con- 
stitution or predisposition ; but constitution or predisposition may much 
modify the character of this disease in different cases; and where the 
agents are less powerful, as in the case of common causes of disease, 
the effects will depend still more on the predisposition, and may be null 
where this is not strong (§§ 15, 19). 

Exciting causes may be divided into cognizable and non-cognizable 
agents. The former class comprehend physical and mental agents, of 
whose existence we can take cognizance, independently of their opera- 
tion in producing disease; thus cold, we know by its effect on our 
instruments and sensations ; muscular exertion, by our witnessing or 
performing it ; and mental emotion, by our consciousness of it. The 
non-cognizable causes, on the other hand, elude our senses, and we infer 
their existence only from their morbific effects; thus malaria and infection 
we know by no other property than that in question. The subjoined 
table includes both classes. 

.1. MechanicaL 
12. Chemical. 
I 3. Ingesta. 
\4. Bodily exertion. 
, Cognizable J5. Mental emotion. 

Agents. ]6. Excessive evacuation. ' 

Exciting Causes j n. Suppressed or defective evacuation. 

OP / I 8. Defective cleanliness, ventilation, and 

Disease. ) \ drainage. 

^9. Temperature and changes. 

II. Non-cognizaWe f i- f"^^'"'? )„ . 



I. Cognizable Agents. 

52 (1). Mechanical causes, which injure structure, or impede or de- 
range function. — Besides the obvious instances of tearing, cutting, pinch- 
ing, striking, and straining, which produce at once diseases which fall 
under the province of the surgeon, the physician finds many mechanical 



54- EXCITING CAUSES OF DISEASE. 

causes of diseases which he has to treat. Long-continued pressure of 
articles of clothing may produce disease. Tight neckcloths may cause 
headache, or even apoplexy, by impeding the flow of blood from the 
head. Tight stays may cause fainting, by pressure on the heart and 
great vessels ; or colic and costiveness, by obstructing the free passage 
through the great intestines. Pressure on the epigastrium, by sitting 
at a desk after a meal, may cause indigestion. Long continuance in one 
position, whether standing, sitting, or lying, will partially obstruct cir- 
culation and innervation, and produce swelling and paralysis of the 
lower parts, or of those beyond the seat of pressure, and in time may 
cause inflammation and death of the parts pressed upon. Mechanical 
causes also operate within the body. A stone in the bladder irritates by 
its mechanical properties, especially if it be of an irregular shape ; or it 
mechanically stops the flow of urine ; so also may a gall-stone that of the 
bile. The intestinal canal is sometimes mechanically stopped by hard- 
ened feces, and irritation and inflammation may ensue. The stomach 
is often irritated by the mechanical qualities, bulk, hardness, or asperi- 
ties of its contents; thence may ensue vomiting, indigestion, or inflam- 
mation of the organ. The air-passages of needle-pointers, stone-masons, 
&c., are irritated and inflamed, and at length altered in structure, in 
consequence of the mechanical action of particles of stone or other sub- 
stances, which these men are continually inhaling in the course of their 
employment. 

Such instances are endless ; and the further efi'ects of disease are also 
in great measure mechanical. For example : the influence of tumors, 
of diseases of the heart and vessels, the lungs and air-passages, intes- 
tines, and urinary apparatus, injuries and diseases of the bones and 
ligaments, &c. &c., is in great part mechanical, interfering with the 
natural mechanism. 

Besides their simple mechanical efl'ects on structures and functions, 
some mechanical injuries, when extensive, directly depress the vital 
powers ; thus, concussion of the brain, crushing or tearing off a limb, or 
a blow on the epigastrium, causes fainting and extreme weakness of the 
heart's action, and may thus cause death. Slighter mechanical injuries 
are causes of irritation or excitement, which may be local or general, 
according to the excitability and extent of the part irritated. 

53 (2). Chemical causes of disease are even more varied than mechani- 
cal, because chemical agents are more numerous. We are acquainted less 
with the chemistry than with the mechanism of the animal body, and 
therefore can less distinguish causes which act by chemical properties 
from those which have complex relations to vital properties. But we 
recognize chemical irritants in acids, alkalies, and many salts, whether 
applied to a part, or inhaled in form of gas or vapor. So what are called 
chemical poisons, such as corrosive sublimate, and other metallic salts, 
the strong acids and alkalies, iodine, chlorine, &c., produce disease by 
their known powerful chemical affinities, which tend to decompose tissues 
and disorder functions. 

We cannot doubt that many of the matters which cause disease in the 
alimentary canal, do so by virtue of their chemical qualities. The pro- 
cess of digestion, although always in part chemical, is so under the 



INTOXICATING LIQUORS. 55 

superintendent influence of a superior vital power ; no sooner does this 
power fail, or the chemical agencies or decompositions become too strong 
for it, than we have fermentation and putrefaction, which cause eructa- 
tion of gas or sour liquid from the mouth, and there may follow the dis- 
charge of ill-colored, and unusually fetid matter by stool ; then, too, may 
arise a number of disorders, which may in great part be referred to the 
influence of these injurious chemical processes. 

There appear to be at least four modes in which chemical agents may 
excite disease in the body : — 

1. As local irritants^ as the diluted acids, alkalies, and various salts, 
the chemical operation of which is resisted by increased action excited 
in the part (§ 16). [The carious maxillBe of the workmen exposed to 
the vapors of phosphorus, would appear to be due to this cause. — C] 

2. As corrosives^ as in the case of strong acids, alkalies, some metallic 
salts, chlorine, and iodine,, which, by their powerful chemical afiinity, so 
completely overcome the vital affinities of textures as to decompose them, 
and thus to kill and alter the condition of the part. 

3. As septics, promoting the spontaneous decomposition of the fluids 
or solids of the body, in the same way that ferments or putrescent mat- 
ters operate on dead organic matter. 

4. As chemical alteratives, modifying the changes which take place 
in digestion, assimilation, transformation of textures, secretions, &c., as 
in counteracting acidity by alkalies, in variously influencing the state 
of the blood and urine by acids, alkalies, &c. ; and in causing the pro- 
duction of hippuric acid in that excretion, by the administration of ben- 
zoic acid. (Ure.) 

The operation of chemical agents on the whole body will vary ac- 
cording to their intensity and extent. Irritants, if extensively applied, 
cause feverish excitement. Corrosives, if acting widely, depress the 
vital powers, like the shock of violent mechanical injuries (§ 52); if 
partially, the vital powers are excited to resist them, and they operate 
as irritants. Septics, if very powerful, may speedily overwhelm the 
preserving vital powers of the body, which then speedily passes into a 
state of corruption, as in the case of extensive gangrene, pestilential 
diseases, &c. ; but if the septic matter be scanty, and the vital powers 
strong, they are excited to increased action, and by means of accelerated 
circulation, and augmented excretions, the body may get rid of the offen- 
sive matter (§ 17). Such struggles are instanced in typhoid fevers, epi- 
demic cholera, dysentery, &;c. 

54 (3). The solid and liquid ingesta are a fertile source of disease, 
and in various ways. Their mechanical and chemical properties have 
already been noticed (§§ 52, 53). But further, the ingesta may cause 
disease — 

a. By non-alimentary matters acting injuriously. 

5. By aliment defective or ill-proportioned in quality. 
c. By aliment defective or excessive in quantity. 

55 (a). Of the non-alimentary matters contained in the ingesta, salt, 
spices, pickles, and other condiments, and spirituous or fermented 
liquors, are frequent exciting causes of disease. They are all more or 
less irritating or stimulating to the digestive apparatus ; and if used in- 



56 EXCITING CAUSES OF DISEASE. 

discreetly, may induce inflammations, congestions, and functional disor- 
ders of these organs, and, in some instances, irritation of other parts, 
and of the whole system. Salt in excess irritates the stomach, retards 
digestion, and causes feverishness with thirst. Much of these eifects 
is due to the affinity of the salt for the water of the animal fluids, and 
may be induced by other saline matters, besides common salt. Wherever 
excess of salt is contained in the body, there will be exosmosis and en- 
dosmosis of the water from the adjoining vessels and tissues, until the 
salt is equally distributed among them ; and before this is accomplished, 
there will be such a diminution of the fluids within the blood-corpuscles, 
and on the surface of membranes, as may readily account for the thirst 
and disturbance caused in the system. According to Liebig, salt im- 
pedes the deposition of fat. Animals will not fatten on salt food; a 
hint for the corpulent. 

56. But the operation of intoxicating liquors is more extended; being 
soon absorbed, their stimulant action is speedily exercised on distant 
parts, especially on the vascular and nervous system. Being absorbed 
by the veins, they pass by the portal vein into the liver, the function 
and structure of which are particularly apt to sufi'er from excesses, 
especially when spirits have been freely indulged in. So, too, the kid- 
neys, which are the natural emunctories through which such extraneous 
matters are eliminated from the system, are often over-stimulated, and 
are injured in their secreting power, and ultimately in their structure 
also. The heart and vessels are over-excited at first, and afterwards 
lose their tone ; and the processes of digestion and nutrition become 
impaired and modified. The nervous system is an especial subject of 
the disordering influence of intoxicating liquors. A large quantity 
taken at a time is a narcotic poison, inducing a short period of cerebral 
excitement or intoxication, followed by insensibility, in which the func- 
tions of the brain are more or less completely impaired, and in extreme 
cases those of the spinal marrow sufier ; and if the influence be insuffi- 
cient to stop respiration, yet it may be imperfectly performed, and con- 
gestions are formed in the brain and other organs. Hence apoplexy, 
palsy, phrenitis, or delirium tremens, may follow, and the whole frame 
may suffer from the eff"ects of the poison. Even when less excessive 
quantities are taken, and their first efiect is mere intoxication, the head- 
ache, sickness, and inappetency, and the feelings of wretchedness and 
depression which often ensue, sufficiently prove that disorder has been 
produced, and that such artificial excitements cannot be abused with 
impunity. 

The habitual indulgence in strong drinks causes further varieties of 
disease, which are so prevalent as to deserve notice. When taken only 
or chiefly with food, not as a substitute for it, but as a constituent of 
general " free living," they contribute to the production of an abundance 
of ill-assimilated, overheated blood ; which either finds its vent in erup- 
tions on the surface, or in local hemorrhages or fluxes, or causes various 
functional disorders, such as palpitation, vertigo, stupor, dyspepsia, bilious 
attacks, &c. ; or may tend to the production of a fit of gout or gravel. 
The latter results are promoted by such beverages as contain much free 
acid as well as an abundance of spirit ; such as port wine, rum punch, 



IMPURITIES IN FOOD. 57 

and hard strong beer. The less acid malt liquors, ale and porter, tend 
rather to induce liver disorders, and an abundant deposition of fat in the 
body. All these consequences will be much favored by sedentary habits 
(§ 24) and deficient excretions ; active exercise carries off much of the 
spirit and superfluous aliment by an increased elimination of the acids 
of respiration and perspiration. 

The most disastrous consequences of intemperance are exhibited by 
the habitual drunkard, who, in proportion as he indulges in liquor, loses 
his appetite for food, and his power of digesting it. He then drinks 
and starves, and the disease which ensues comprises the exhaustion of 
inanition with the more direct effects of the alcoholic poison. Thus, in 
delirium tremens, the drunkard's disease, together with the permanent 
restless excitement of the irritated nervous system, which adds more 
and more to the exhaustion, the weakness of mind and body is fearful, 
and in bad cases affect even the organic functions, so that the pulse is 
very weak and frequent, the excretions scanty and depraved, and the 
respiration is too imperfectly performed by the involuntary powers to 
permit sleep to ensue. This exhaustion must soon terminate in death, 
unless prevented by appropriate treatment ; and this must comprise, 
besides opium (the common remedy), ammonia and other stimulants to 
the circulation and respiration; purgatives and diuretics to free the blood 
from the excrementitious matter that has accumulated in it ; and fluid 
nourishment to repair its waste. Without these adjuncts, opium will 
not only fail to procure sleep, but its narcotic influence may extinguish 
the flame of life. 

Pernicious as fermented liquors are in their abuse, yet these and other 
adjuncts to food, when taken with careful moderation and discrimination, 
often prove beneficial by aiding the digestion where it is weak, and by 
counteracting various exhausting and depressing influences, which are 
frequently arising out of the artificial condition and employments of 
society, especially in large towns and in cold climates. Total abstinence, 
therefore, is preferable to moderation, only because it is morally easier 
to practise, not because it is more salutary in its physical effects. 

57. Disease may be excited by unwholesome articles with which the 
food is adulterated. To this class of causes belong various poisons ; 
the operation of some of these will be noticed under the head of modes 
of death (see chapter on Prognosis) ; but for further details, works on 
toxicology and materia medica must be consulted. There are some 
noxious matters occasionally mixed with food, which gradually produce 
deleterious effects. Thus salted provisions too long used will cause 
scurvy ; ergotted corn has been known to produce dry gangrene. Lead, 
gradually introduced, causes constipation, colic, paralysis, and atrophy. 
Impure water, used as a drink, is a common cause of disease; containing 
decaying vegetable or animal matter, it may induce sickness, diarrhoea, 
cholera, and typhoid symptoms ; hard waters, which are impregnated 
with some of the salts of lime, render the bowels costive, and are sup- 
posed to favor the production of calculous diseases and bronchocele ; 
brackish waters, containing saline matter, may induce dyspepsia and 
diarrhoea ; chalybeates, containing iron, are constipating, &c. 

Under the head of non-alimentary ingesta which may cause disease, 



58 EXCITING CAUSES OF DISEASE. 

we must reckon various medicines ; and that not only when injudiciously 
administered, but as commonly prescribed ; the remedies necessary to 
cure or relieve many diseases, are not uncommonly necessary evils ; they 
remove one disorder by inducing another, and it is well if the evil thus 
induced is the smaller of the two. 

58 (6). Aliment unfit in quality is another condition of the ingesta 
that may cause disease. Man is by nature and habit an omnivorous 
animal ; and in general, his health is best maintained by mixed propor- 
tions and varieties of animal and vegetable food. The insalubrity of the 
simpler constituents of food, when separate, even those supposed to be 
most nutritive, has been well shown by the numerous experiments of 
Magendie, Gmelin, and others. They fed dogs, geese, donkeys, and 
other animals, on articles which are generally considered highly nutritive, 
as sugar, gum, starch, oil, or butter ; the animals died with symptoms 
of starvation almost as soon as if they had been kept without food. Even 
bread, when too fine, is insufficient for nutriment. A dog fed on pure 
white bread lived only fifty days, whereas another fed with the coarsest 
brown bread was well nourished, and seemed capable of living to an inde- 
finite period. According to the researches of a commission of the French 
Institute (the report of which was published in 1841), animals fed on 
pure fibrine, or albumen, or gelatine, die of starvation, with reduced 
quantity and quality of the blood, almost as soon as if not fed at all. 
Gluten, or vegetable albumen, is the only simple principle which will 
alone maintain life, and the nutritious qualities of vegetable food depend 
chiefly on the quantity of this azotized principle which they contain. 
Bread may, therefore, well be called the staff of life. Even animal albu- 
men and fibrine require mixture with vegetable matter to make them 
properly nutritious as well as wholesome ; and gelatine and oily matters 
are still less available for nourishment without much combination. In 
the experiments just alluded to, animals could be supported on meat or 
flesh, which comprises several of the elementary matters, although they 
were not sustained by any one of these matters separately. 

The utility of a due combination of organic elements for the food of 
animals has long been ably shown by Dr. Prout, who has pointed to 
Nature's aliment, milk, as the great type of all proper kinds of nourish- 
ment ; as it contains albumen, oil, sugar, and water,, so all other kinds 
of food used for ordinary sustenance, ought to include these elements, 
or others isomeric (that is, identical in ultimate composition) with them ; 
and it is quite true that all combinations of food sanctioned by custom, 
do comprise such ingredients. Bread contains two of these, gluten, 
which is vegetable albumen, and starch, which is isomeric with sugar; 
but bread is not relished without butter or some fat with it. Neither 
does meat, which contains albumen and fat, suit the taste without a com- 
bination with bread, rice, potatoes, or some vegetable, which represents 
the amylaceous or saccharine principle. 

59. Much discussion has occurred of late as to the share or purpose 
which each of the elements of food serves in the animal economy, and 
the extent to which they can be chaiiged by the process of digestion and 
assimilation. Dumas and the French chemists generally have maintained 
that this process is limited to the separation and appropriation of princi- 



ILL-PROPORTIONED FOOD. 59 

pies ready formed in the food, and does not extend to the conversion of 
one into another. Thus all the albumen or fibrine in the body is derived 
from the albumen or gluten of the food ; and all the fat from fat or oil 
contained in the nourishment. This view, as regards the formation of 
fat, is opposed by many familiar facts, such as the fattening of domestic 
animals with farinaceous and vegetable foods, which contain very little 
fat ; and it has been completely negatived by the experiments of Petroz 
and Boussingault, which have proved that geese and pigs, during the 
process of fattening, gain more fat than is contained in their food.^ It 
further appears probable that the conversion of sugar into fat is promoted 
by the agency of bile ; for H. Meckel found that, by keeping a mixture 
of bile and grape sugar at a warm temperature, the quantity of fat in 
the mixture increased to double in five hours, and more than treble in 
twenty-four hours. It is pretty certain, therefore, that fat may be formed 
from starch or the saccharine principle, and probably from the albumi- 
nous also. But there is no decisive evidence to show that albumen or 
gelatine can be elaborated from fat, starch, or sugar, at least under com- 
mon circumstances ; and it is certain that these elements alone will not 
long sustain animal strength or life.^ 

Baron Liebig has advanced a very comprehensive hypothesis with re- 
gard to the purposes of the different proximate elements of food. He 
considers that the albuminous principle alone supplies the material from 
which the textures are nourished, and all the non-nitrogenous elements 
are converted into carbonic acid and water by the process of respiration 
for the production of animal heat. Although too exclusive to be fully 
admissible, the general outline of this view appears to be consistent with 
facts, and will assist us in studying variations in food as a cause of dis- 
ease. 

60. The chief alimentary matters may be divided into the albuminous^ 
the gelatinous, the oleaginous, and the saccharine, or amylaceous ; and 
we shall briefly consider how an excess or defect, and in some instances 
the quality, of each of these may operate in causing disease. 

Albuminous or proteinaceous articles, such as the lean of meat, fowl, 
and fish, gluten of bread, and caseine of milk, are those which supply 
the albumen and fibrine of the blood and textures of the body. Hence 
defect of this kind of nourishment will cause first, weakness of the heart 
and other muscles, and at length wasting of these and of other textures, 
with diminution of the quantity and richness of the blood. Excess of 
carneous food, particularly the richer kind, butcher's meat, tends to 
cause plethora, with an excited circulation and feverishness, which may 
result in hemorrhage, inflammation, gout, lithiasis, &c. 

Bad quality of albuminous food is peculiarly injurious to persons 
of weak digestive and assimilative powers ; thus the caseine of cheese 

1 Dr. Day's Report on Chemistry, in Dr. RanMng's Abstract, July, 1846 [p. 273, Am. Ed.]. 

2 In a very able paper on Vital Affinities, just published by Dr. Alison ( Transac. of Royal 
Sac. Edin. 1847), he adduces many arguments in favor of the inference that albumen may 
be formed in the animal body, especially in vigorous health ; and he suggests that the inter- 
vention of ammonia can furnish the material from which starch and other non-azotized arti- 
cles of food receive azote, and by the power of the vital affinities are converted into albu- 
men. There is much reason on the side of this notion ; it may be seen that I have long 
entertained a similar opinion with regard to the conversion of gelatine into albumen. 



60 EXCITING CAUSES OF DISEASE. 

the fibrine of stale or salted meats, and the gluten of sour or ill-baked 
bread or heavy pastry, instead of forming good proteine, is apt to de- 
generate into the products of animal decay, lithic and lactic acids, urea, 
&c. Hence may arise gout, rheumatism, calculous disorders, &c.^ 

G-elatinous foods, soups, broths, isinglass, jellies, &c., are by no means 
so supporting as albuminous matters ; but Tvhen combined with bread, 
they nourish the body so \vell that it seems very probable that, in a 
healthy constitution, gelatine may assist in the formation of albumen ; 
but when used in excess, or to the exclusion of bread and meat, it ceases 
to be nutritious, and the strength and flesh will waste. 

Oleaginous or fat nutriment (butter, fat of meat, oils, and seeds con- 
taining them), not only supplies the material for the adipose textures of 
the body, but it assists in the formation of other structures and secre- 
tions (oil globules forming a normal constituent of them), and it affords 
the strongest fuel for the maintenance of animal heat by respiration. 
Erom what has been before stated (§ 59), it may be inferred that fat 
may also be formed from saccharine and starchy food, as well as from 
the storehouses of the adipose membrane ; but defect of fat in the food 
has been observed to induce the following morbid results ; loss of flesh, 
especially of the rounded plumpness and smoothness of the surface, which 
becomes skinny, wrinkled, and often dry and scurfy ; deficient secretion 
of mucus at the orifices of mucous passages, and of synovia in the sheaths 
and joints ; insufiicient formation of bile, and consequent imperfect 
digestion and feculent excretion, with diminution of animal heat. Ex- 
cess of fat food may disorder the stomach, by its indigestibility, be- 
coming rancid, and causing heart-burn or sickness, and sometimes a 
bilious taste ; for much fat seems to induce a regurgitation of bile into 
the stomach, which is supposed to assist in its digestion (Beaumont) 
and absorption (Matteucci). If the fat is carried into the blood, it may 
cause inconvenient obesity by its accumulation in the adipose texture of 
various parts of the body ; or if the subject be naturally lean, and in- 
capable of accumulating fat, the superfluity must be carried off, and the 
natural emunctories, the sebaceous follicles of the skin, and the liver, 
may be disordered ; hence acne and other follicular diseases of the skin, and 
various bilious disorders, will ensue. These results will be more readily 
produced in sedentary persons, in whom the exercise of the lungs is in- 
sufficient to consume the superfluous fat. On the contrary, those who 
use active exercise can often take considerable quantities of fat with 
impunity, and sometimes with advantage. For similar reasons, oily 
food is better borne in cold than in hot climates and seasons ; thus, as 
Liebig has pointed out, the Laplander relishes train oil, which serves to 
sustain the warmth of his body ; whilst the Italian, in a sunny climate, 
prefers the less combustible food, maccaroni and fruit, which nourish 
without heating. 

1 In this statement I disregard the dogma of Liebig, that the materials of food serve for 
respiration and nutrition only ; and that urea, lithic acid, and excrementitious matters are 
derived from the decaj^ of the tissues alone. Daily observation convinces the medical 
practitioner that in persons of weak assimilation, certain articles of food, as specified 
above, so certainly and promptly cause an increase of animal matter in the urine, that 
there can be no doubt that they are the dii-ect sources of it. 



ILL-PROPORTIONED FOOD. 61 

The quality of oily matter in the food is materially concerned in its 
morbific efi'ects. those most prone to chemical change or to become solid, 
being more likely to disagree than others. Thus stale or tainted butter 
or fats, and rancid oils, are peculiarly offensive to the digestive organs, 
both from the production of injurious acids (butyric and oleic), and 
from their spissitude rendering them incapable of the minute division 
necessary for their absorption and appropriation to the nutritive pro- 
cess. On the other hand, fresh butter, mild fat, and sweet salad oil, 
agree well and nourish, especially when intimately blended with fari- 
naceous or succulent vegetable matters ; and the cod-liver oil, when freed 
from its impurities, is often borne by the weakest stomachs. 

Amylaceous or starchy foods, such as arrowroot, sago, tapioca, and 
many kindred preparations of farinaceous articles, although isomeric 
(i. e. consisting of the same elements) with saccharine matter, are not 
quite similar in their physiological effects. Like it, they probably sus- 
tain the body rather by supplying a material for the process of respira- 
tion, than by nourishing the textures ; they thus save them from the 
consuming influence of the oxygen absorbed through the lungs ; and if 
taken in excess^ they may either lead to the formation of fat (§ 59), 
which is deposited in the textures, or, passing into fermentation, they 
may give origin to acetic, lactic, and oxalic acids, and other matters of 
an injurious tendency ; and this latter effect occurs more from saccharine 
than from amylaceous food. On the alimentary canal, too, their effects 
in some degree differ, amylaceous food in excess impairing the action of 
the intestines, and the secretion of the liver, whereas sweet things often 
relax the bowels and cause a redundancy of bile. These different ef- 
fects of saccharine matter are probably connected with its either often 
containing or readily forming vegetable acids, which irritate the aliment- 
ary canal, and which may become causes of dyspepsia, diarrhoea, dia- 
betes, rheumatism, oxaluria, and other disorders of the same class. 

Amylaceous and saccharine matters, forming the mildest materials of 
food, serve to dilute the stronger articles, fibrine and oil, and to render 
them both more palatable and more digestible ; when, therefore, the 
former are deficient^ the latter are more apt to disagree, and fail to im- 
part their nutrient properties. These and other vegetable principles 
such as gum, vegetable jelly, extractive, &c., also contain an alkali 
combined with vegetable acids which are decomposable in persons of 
strong dicrestion, and this alkali becomes useful in counteracting the 
acidity which results from the processes of transformation continually 
proceeding in the body. Thus fruits and other vegetables assist in neu- 
tralizing and eliminating lithic acid, and in preventing the occurence 
of gout and gravel. This statement is in accordance with the views of 
Prout, Liebig, and Wohler ; but I have restricted its application to 
the case of persons whose digestion is strong ; for in those of feebler 
powers, I find commonly that vegetable acids and fruit increase the 
acidity of the urine, and are therefore injurious ; whether by passing 
unaltered through the circulation, or by irritating the primte vice, 
and thus leading to an unusual development of hydrochloric and other 
unchangeable acids, I cannot say, but the latter would appear most 
probable. 



62 EXCITINa CAUSES OF DISEASE. 

61. Thus the selection and combination of articles proper for food 
would be a difficult task, requiring much scientific knowledge and cal- 
culation, were it not that Kature has supplied us with an instructive 
guide, which happily adapts itself to the varied wants of the system, in 
change of season and other circumstances. The appetite and taste 
generally instruct us pretty safely as to the best proportions of difi'erent 
kinds of food ; but they must not be perverted and pampered by condi- 
ments, and refined modes of cooking. These are expedients to coax and 
deceive the appetite and taste ; and if these guardians of the nutritive 
department are cheated, it is no wonder that the department becomes 
deranged. 

62 (c). Aliment may be excessive or deficient in quantity. Some- 
times the appetite is inordinate ; more frequently it is pampered ; in 
either case, if gratified, more food is taken than the expenditure of the 
system requires. If the digestive organs fail in appropriating the 
nourishment, they become distended, irritated, and otherwise disordered 
by what they cannot digest. If they are strong, and digest the excess, 
they send too much chyle into the blood, over-distend the vessels, and 
derange the function of assimilation; hence may result plethora, apo- 
plexy, gout, gravel, or some congestive hemorrhage, or inflammatory 
disorder, to which the individual is predisposed (§ 14). Such evil con- 
sequences of repletion will ensue the more readily in sedentary persons, 
in whom the waste of the body is little, and the excretions scanty. 

63. Defective nourishment may excite various disorders. In the ex- 
treme case of privation of food, the cravings of hunger are alternated 
with nausea and a sense of sinking ; then follow extreme depression 
alternated with transient fever, delirium, and general disorder both of 
body and mind, with increasing feebleness, and inability to maintain 
animal heat. It is a curious fact, that, in this state, the stomach be- 
comes inflamed ; probably from the irritating action of its secretion on 
its unrelieved vessels. Even in less degrees of abstinence, enjoined in 
the treatment of disease, symptoms of vascular and nervous irritation 
often arise in the midst of general weakness. By many practitioners 
of the Broussaian school, these symptoms are erroneously taken as indi- 
cations for an increase of the antiphlogistic plan, when a judicious return 
to nourishing food will really prove the best cure. Deficiency of food, 
if long continued, causes general weakness of the functions, and wasting 
of all the textures, except those of the nervous system. The blood be- 
comes thin and easily extravasated ; the gums spongy and bleeding ; 
fat disappears ; muscles become thin and flabby ; the legs oedematous ; 
diarrhoea often occurs ; ulcers appear in the cornea and other parts 
which are least vascular ; a state of scurvy or cachexy is induced, from 
which, if advanced, an improved diet may now fail to restore. Chossat 
found that, in animals gradually starved to death, the temperature pro- 
gressively declined, and, unless maintained artificially, the animals 
seemed to die of cold. All the textures, even that of the bones, sus- 
tained great loss of weight ; but those of the nervous centres far less 
than any others. This fact I would explain by the peculiar condition 
of the bloodvessels supplying these centres, which enables them to mo- 
nopolize the little blood remaining; and thus we gain a further interpre- 



QUANTITY OF FOOD. 63 

tation of the predominance of nervous symptoms in persons suffering 
from inanition. (See Anemia.) In less extreme cases, poor living 
may excite scrofulous and tuberculous disease, and other kindred forms 
of degeneration of organs. The bad influence of poor living is much 
more felt in those who are confined in close habitations, as in prisons, 
poor-houses, the cabins of ships, and besieged towns, than in those who 
are at large (§ 22) ; and it is under such circumstances, that the insalu- 
brity of some kinds of food, however nutritious, becomes apparent. 
Thus, even bread, with meat or broth, will not preclude the occurrence 
of scurvy ; but a suflScient addition of fresh vegetables, and even of 
potatoes, prevents this disease from appearing. — (Dr. Baly, Med. Grct- 
zette, Feb. 1843.) 

[Chossat has shown that by nourishing any animal insufficiently, 
instead of totally depriving him of nourishment, the period of death 
is delayed, but it does not change the law that death occurs sooner 
or later inevitably. In both cases, the animal dies as soon as his 
weight attains the limit of diminution compatible with life. Before 
the decisive experiment of Chossat, many observers, Regnault, Reiset, 
and Hebray amongst others, had shown that the effects of insufficient 
nourishment were similar to those following complete inanition. The 
progress of the phenomena of the two sets of causes in the animal 
economy, offers only the differences which we notice in the course of an 
acute and a chronic affection. In both instances we have vomiting, 
diarrhoea, progressive cerebral debility, and muscular atony so complete, 
that the natural function, contractility, is destroyed. The action of the 
stomach ceases, the ingesta act as foreign bodies whose presence induce 
gastric irritation, veiled by the general dynamic disturbance. Every 
cutaneous solution of continuity, no matter how slight, becomes an 
intractable sore, attended with hemorrhage. Finally, convulsions, 
complete neurosthenia, intense marasmus, and death. 

Defective nutrition plays a large part in the direct production of 
diseases. Fever, malignant dysenteries, and other disorders of that 
class, have been the invariable attendants on all the great famines in 
Europe. The following graphic description of the effects of insuffi- 
cient nourishment in the last great famine of 1846-47, which ravaged 
Ireland, the Belgian Flanders, a portion of Germany, and several 
departments of France, is from an eye-witness, M. de Mursman: 
" The first stage of the disorder was characterized by all the symp- 
toms belonging to an impoverished condition of the blood ; palor, loss 
of flesh, sadness, depression, difficult digestion, flatulence, disordered 
dejections, distension of the abdomen, oedema of the extremities, either 
suppression or unusual abundance of the menstrual discharge, sterility, 
general debility of the muscular system, pain in the limbs, embarrassed 
and painful locomotion, and impossibility to labor. In this condition 
the human being merely vegetated, and dragged on a miserable existence, 
soon, however, to experience trials still more severe ; for, in proportion 
as the state continued, and in direct proportion to the debility in 
each individual, chronic affections peculiar to his constitution or his 
profession were developed ; specific disorders, which had remained sta- 
tionary, in a static embryonic condition, or one of simple predisposition, 
broke forth violently. Hence, syphilitic affections, psoric, strumous, 



64 EXCITING CAUSES OF DISEASE. 

cancerous, herpetic, dartrous disorders, pursued their ravages, and claimed 
the first victims in this alimentary crisis. Of all the cachexise, phthisis 
pulmonalis furnished the largest contingent to the bills of mortality. 
The unfortunate beings who did not succumb to some one of the af- 
fections which privation had produced, and in whom some remains of 
organic vigor still existed, became daily more and more debilitated 
under the influence of a diet that the organs could but imperfectly 
assimilate. The appearance of these unhappy victims of deficient 
nourishment was striking ; — their bodies were horribly emaciated ; their 
jaws hollow, and their physiognomy peculiar ; the whole vitality of the 
individual seemed concentrated in the eye, which was unnaturally bril- 
liant, with an enormously dilated pupil ; and the look was fixed, and 
characterized by an interrogative astonishment, in which good-nature 
w^as mingled with fear. The movements of the body were slow ; the 
walking halting, the hands trembling, and the voice feeble and bleating. 
The mind was no less notably affected ; questions were answered slowly, 
and memory in the greater part almost extinct. When questioned as to 
the nature of their disease, these unfortunates all answered that they did 
not suffer except from hunger. The breath was fetid; the tongue 
narrow, pointed, oblong, and trembling, nearly always red at the tip, 
often aphthous, and constantly covered with a thick yellow coating. The 
epigastrium was shrunken, and seemed to stick to the vertebral col- 
umn. The respiration was slow and sobbing. The pulse was either very 
quick, or remarkably slow, easily compressed, of astonishing smallness. 
All the secretions participated in the great alteration of the blood, which 
is their source, but it was especially the cutaneous transpiration which 
was modified. The skin was yellow, dry, and resembled parchment. 
Its pores secreted a viscous dust, which accumulated and concreted as a 
blackish, pulverulent crust, horribly fetid. This condition of the skin 
was at first attributed to uncleanliness ; but in such of the sufferers as 
were sent to the hospital, baths were in vain tried to restore the natural 
appearance and function of the integuments ; in an hour after com- 
plete cleansing, the skin would be again covered with this anormal 
secretion. On touching the skin the sensation was acrid and biting, 
and the hand for some time afterward was impregnated with a disagree- 
able odor." Such is a truthful picture of the effects of continued de- 
fective nourishment on the human being. And Chomel observes: — 

"The prolonged use of a scanty regimen is a frequent cause of obsti- 
nate constipation and various digestive troubles, in those who fast 
throughout Lent," a fact annually verified in the writer's practice. — C] 

64. (4). Excessive hodiJy exertion of various kinds is a common ex- 
citing cause of disease. General muscular efforts, as in running, walk- 
ing up hill, rowing, &c., hurry the movement of the blood back to the 
heart, and resist its distribution through the arteries in such a degree 
that the heart, the lungs, the brain, and other organs, have an unusual 
pressure of blood upon them (§ 51). 

The heart, excited to inordinate action, is often strained and distended, 
and its function, or even its structure, and that of the great vessels, may 
be impaired in consequence. This is especially apt to happen if there 



BODILY EXERTION. 65 

be anything already imperfect in the structure of the organ, its valves or 
vessels ; and there are naturally very various degrees of perfection and 
strength in these parts. 

The brain is particularly liable to suifer from violent exertion, espe- 
cially if joined with a stooping or constrained posture ; for its vessels are 
not, like those of the limbs and trunk, supported by muscular pressure 
upon them, and the excited heart can therefore send its blood into them 
with more force. Hence giddiness, noise in the ears, deafness, defect- 
ive vision, convulsions, palsy, and apoplexy, have been brought on by 
violent exertion. 

The lungs are also apt to suffer ; for the blood being returned to them 
faster than they can arterialize it, they become greatly congested; hence 
cough, dyspnoea, haemoptysis, or inflammation of the lungs, may ensue; 
and the texture of the lungs may also sustain injury in consequence of 
the violent strain to which it is subjected by the increased exertions for 
breath. 

Other internal organs sometimes are disordered by the blood thrown 
or retained in their vessels by the pressure of external muscular action. 
Derangement of the liver, hsematemesis, hsemorrhoids, and haematuria, 
have been brought on by such a cause. The sharp pains or stitches felt 
in the sides or abdomen, on running fast, are commonly supposed to be 
in the liver or spleen ; but more probably they are spasms of the intes- 
tines — temporary colic, produced by irregular pressure on them, when 
their sensibility is raised by the blood unduly thrown into them. 

Some kinds of muscular exertion peculiarly affect certain organs. 
Thus loud reading or speaking, or blowing wind instruments, especially 
tries the organs of respiration and the voice, and may cause hemorrhage, 
inflammation, and various diseases of these organs. Excessive or rough 
riding or leaping may injuriously affect the kidneys and organs of gene- 
ration. Straining to lift a heavyweight, or at stool, or in any continued 
effort, which implies holding the breath, endangers the structure of the 
vessels of the chest and brain, on which there is no equally counteract- 
ing muscular pressure. 

Bodily exertion, long continued, may also cause disease by its exhaust- 
ing effects. In extreme degrees, this exhaustion may amount to syncope, 
and even death ; short of this, it may cause great weakness of muscles 
and of the heart, with corresponding depression of other functions, with 
congestion of the viscera, defective assimilation and excretion ; hence 
arises the low typhoid or adynamic fever which sometimes follows pro- 
longed fatigue. In slighter cases, we have giddiness, faintness, nausea, 
loss of appetite, indigestion, costiveness, amenorrhoea, and other varieties 
of injured function. When exercise is carried on so long, or to such a 
degree, as to impair the organic functions, it thereby induces disorder in 
them in addition to the weakness, prostration, and actual suffering in 
the animal functions. A serious part of such disturbance is the sleep- 
lessness which ensues from extreme fatigue, and which may bring the 
patient into a state resembling that of delirium tremens. This, as we 
have already mentioned under the head of predisposing causes (§ 23), is 
mainly due to the state of the respiration, which being insutliciently 
maintained by the weakened spinal function, is aided by continued vo- 
5 



66 EXCITING CAUSES OF DISEASE. 

luntary efforts, which are manifest in the frequent sighing that takes 
place. In this case, the best hypnotic will be found in a diffusable 
stimulant. 

65. The opposite extreme, want of exercise, is capable of exciting as 
■well as of predisposing to disease (§ 24). Thus internal congestions, 
deficient and disordered secretions, general plethora, over-nourishment 
of adipose texture, and wasting of muscles, and various evil conse- 
quences of these morbid conditions, may result from this cause when long 
in operation. When combined with some of the other disturbing in- 
fluences noticed in this section, it is a still more ready and common 
cause of mischief. Some organs more particularly suffer from a seden- 
tary mode of life ; for example, the liver, from the increased task of 
decarbonization of the blood which deficient respiratory exercise throws 
on it ; the brain, from its vicinity to the centre of the circulation, ex- 
posing it to an accumulation of blood when the distant circulation fails; 
hence bilious disorders, dyspepsia, hemorrhoids, headache, giddiness, &c. 

66 (5). Strong mental emotion or acute sensation, is a common cause 
of disease. Closely knit together as the mind and body are, it is not 
surprising that they should ever be ready to affect each other, and that 
when the impression is strong, the affection should not be slight or tran- 
sient. The heart most remarkably suffers from such causes. Thus a 
sudden shock, whether of grief, surprise, fear, or even joy, may cause 
fainting, partial suspension of the action of the heart ; nay, even death 
has ensued; and the expressions "frightened to death," and "killed with 
joy," are not always mere figures of speech. Sudden acute pain often 
causes fainting. Palpitation and irregular action of the heart are very 
common effects of emotions. 

Other parts also suffer from strong moral impressions. Spasmodic 
asthma and spasmodic affections of the throat are sometimes thus in- 
duced. Apoplexy, palsy, inflammation of the brain, epilepsy, and 
insanity, have been caused by excessive anger, terror, surprise, and joy. 

Very commonly, mental emotions affect the secreting organs, and es- 
pecially the functions of the alimentary canal. A piece of very bad 
news takes away appetite, or impairs digestion. Fright or anxiety often 
loosens the bowels, or brings on a bilious attack, or jaundice. The 
uterine periodic function is remarkably subject to the influence of moral 
emotions, and many of its disorders may often be traced to this source. 

The slower emotions of the mind and over-exertion of its faculties are 
also exciting causes of disease. Long-continued depression or anxiety 
sometimes induces dyspepsia, costiveness, or diarrhoea, asthma, and 
functional disorders of the heart, menorrhagia, and dysmenorrhcea ; and 
in time, structural diseases of the same parts occasionally follow these 
, functional affections. Over-exertion of the faculties, or excitement of 
the passions of the mind, is chiefly felt in its own functions, or in its own 
organ, the nervous system. Hence may arise congestions of the brain 
and exhaustion of nervous power, with giddiness, stupor, headache, dull 
and disordered sensation, and even apoplexy and palsy. Or the disease 
may be inflammatory, with symptoms of irregular excitement, nervous- 
ness, delirium, tremor, convulsion, partial paralysis, &c. Sometimes the 



EXCESSIVE EVACUATION. 67 

effects of excessive mental exertion or moral emotion are apparent only 
in the phenomena of the mind, the powers of which are injured or dis- 
ordered, and various forms of insanity are produced. When we consider 
the variety and amount of food and condiment, employmcDt and excite- 
ment, that pass into the minds of persons in the busy and worrying scene 
of civilized life, it is not extraordinary that the mind, as well as the 
digestion or other function, should occasionally be disordered by such 
causes. 

67 (6). Excessive evacuation or loss either of blood or of some secre- 
tion, was formerly noticed (§ 28) as a cause of debility, which predis- 
poses to other diseases; but if the loss be great or sudden, it may pro- 
duce immediate disease. A certain fulness of the heart and bloodvessels 
is required for their healthy functions, as well as for those of all the or- 
gans which they supply. If a moderate quantity of blood be suddenly 
withdrawn, or a large quantity less suddenly, the heart's action will be 
impaired, rendered irregular, and may be interrupted, and the brain not 
receiving a current sufficient to maintain its functions, there may be 
fainting, with loss of consciousness, accompanied or followed by disorder- 
ed function, palpitation, delirium, convulsion, or by death. The sudden 
impression in these cases is evidenced more on the brain than on the 
heart; for these effects may be induced by the loss of a much smaller 
quantity of blood in an erect or sitting posture than in a horizontal 
posture. Similar results have been found to ensue from the sudden re- 
moval of pressure from the vessels in any considerable part of the 
body, as by the discharge 'of the fluid of ascites, or by inclosing a limb 
in an exhausting tube. (Dr. Arnott.) Lower mentions a case of ex- 
tensive varix (enlargement) of the veins of the lower extremities, in 
which the patient could not stand without fainting, until the legs were 
bandaged. In these cases, much of the blood, although not removed 
from the system, gravitates into vessels, where it becomes unavailable 
for the general circulation. The fainting which occurs in these cases 
is called cerebral syncope^ because the functions of the brain are sus- 
pended, consciousness is lost before the heart's action is interrupted; 
but the disorder of the brain reacts on the heart, and adds another in- 
fluence to impair its action also. This is Dr. Alison's explanation. 
On the other hand, if the hemorrhage is gradual, and the posture hori- 
zontal, other functions fail before the consciousness is lost — the chief 
symptoms being "feebleness of muscular action; paleness and collapse 
of the countenance ; coldness, beginning at the extremities ; cold sweat, 
beginning on the face ; the pulse imperceptible," and the heart's action 
becoming so. The true nature of these effects, and the reaction and 
nervous symptoms with which they are often followed, will be consider- 
ed hereafter in connection with the subject of anaemia. 

Not only bloodletting, but other evacuations, purging, sweating, and 
vomiting, the catamenial and seminal' discharges in excess, are capable 

' [A man who, during his whole life, has exposed himself witli impunity to the incle- 
mencies of weather, is attacked with rheumatism, when exposed after excessive venereal 
indulgence. Under similar circumstances, the same disposition to attacks of yellow fever 
was noticed at St. Domingo ; and Diemerbroeck remarked at Nymegen, that all who 
married during the continuance of the plague, were attacked with the disease soon after- 
wards. (Chomel). — C]. 



68 EXCITING CAUSES OF DISEASE. 

of producing syncope and general debility. The depression and faint- 
ness induced by these, although less prompt, are often more permanent 
than those from bloodletting ; for such evacuations imply, not only re- 
duction in the mass of blood, but also an exhaustion of the vital ener- 
gies in the secretions and functions concerned in producing them. 

The diseases gradually induced by these several causes of evacuation, 
are seldom of a simple kind. General vreakness of the muscles and 
functions is commonly a result ; but this is often complicated by symp- 
toms of partial reaction, palpitation, spasms, noises in the head, images 
in the sight, pains in different parts, sometimes very acute, but seldom 
long fixed, partial paralysis, and a defective and disordered state of the 
excretions. 

68 (7). Deficient evacuation of excrementitious matter, whether na- 
tural or accidental, is a very fertile source of disease. The operation of 
this class is somewhat diversified, some causing disease by the positively 
noxious influence of matter retained in the system, which is the case of 
the excretions of urine and feces ; others, by causing fulness of the ves- 
sels, and the various disorders which this may induce. To the latter 
cases belong sudden suppression of hemorrhages, or other discharges 
which have become habitual. 

The matter of alvine and renal excretions is essentially pernicious, 
and cannot be long retained even in their natural repositories without 
causing mischief. Feculent matter, when it has reached the large in- 
testine, is still acted on by the absorbents, which take up its more fluid 
parts, and with them, if long retained, fetid matter, which ought to be 
excreted. The solid residue becomes hard and scybalous, and may re- 
main lodged in the cells of the colon, a cause of irritation, distension, 
and obstruction (§ 51). Sometimes the system suffers before the intes- 
tine itself; at length, however, or sometimes at first, this part becomes 
irritated ; colic, diarrhoea, and inflammation may ensue — nay, in some 
instances, where efficient remedies are neglected, even ulceration and 
other structural changes take place, before the off'ending matter is dis- 
lodged. 

The retention of urine has even more serious effects. Besides me- 
chanical distension, irritation, and rupture, which may follow from the 
constantly accumulating secretion (§ 51), the fluid is partially reab- 
sorbed, giving a urinous smell to the breath and perspiration, and some- 
times causing typhoid symptoms, which in extreme cases prove fatal, 
with delirium or convulsions, and coma ; and eff'usions of serum, con- 
taining urea, are found in the brain, chest, and other parts. These are 
effects more commonly of suppression than of mere retention ; but, in 
fact, suppression often follows retention ; the retained urine is prone to 
decomposition (§ 53) ; highly irritating and offensive matters are pro- 
duced, which cause injury to the bladder, rapidly extending up the 
ureters to the kidneys, whose function then becomes impaired or sup- 
pressed. In several cases of the early stage of the severest form of 
Bright's disease, in which the urine was very scantily secreted and high- 
ly albuminous, I have seen typhoid symptoms of the worst character 
ensue, accompanied by a breaking up and partial solution of the color- 



DEFECTIVE EVACUATION. 69 

ing matter of the blood, with the appearance of pus globules in it ; in 
two instances, there was effusion of a bloody purulent fluid into the 
joints a day or two before death ; these results will be further noticed 
under the head of defective excretion and purification of the blood as 
an element of disease. Checked perspiration is a well-recognized cause 
of disease, commonly of a febrile or inflammatory nature ; but the sud- 
den suppression of a fetid sweat in the feet, axillae, &c., has sometimes 
been followed by such serious disturbance of the health, as plainly in- 
dicates that the matter thus excreted is of a noxious quality. 

The preceding are extreme results; but the attentive observer will 
find that smaller degrees of the same causes, insuSicient secretion, or 
insufiicient evacuation of excrementitious matters, are among the com- 
monest sources of disorder; and it is by a proper restoration of these 
functions that the almost universal domestic remedies, as well as the 
common pills and draughts of the surgery, prove so useful in preventing 
as well as in removing disease. We shall have many occasions to 
illustrate these facts. 

Numberless maladies arise from suppression or irregularity of the 
catamenial discharge, which appears to be a highly carbonized blood, 
and therefore its excretion gives relief. Diseases are not unfrequently 
excited or rendered active at the period of its total cessation. The same 
may be said of the secretion of milk. The disorders which 'these first 
produce are commonly connected with local or general plethora; but 
eventually the quality of the blood in the body becomes altered as these 
excrementitious matters are suppressed. 

69. An artificial or diseased discharge or secretion, as that of a seton 
or issue, or from an ulcer or diseased membrane, or an unnaturally pro- 
fuse flow of an ordinary secretion — such as looseness of the bowels, if 
so long established as to have become habitual — cannot be suddenly 
suppressed without great risk of exciting disease. In the case of ha- 
bitual puriform or sanious discharges from setons, issues, and old sores, 
their sudden suppression has sometimes given rise to the most formida- 
ble symptoms, showing that a noxious matter had been thrown back 
upon the system ; and the fear of such accidental suppression, which 
cannot be always prevented, deters me from frequently employing these 
artificial drains in the treatment of disease. Habitual hemorrhages, as 
from the nose or rectum, and the practice of periodical bloodletting, 
cannot be abruptly checked with Sfifety. The maladies which result 
will vary with the predisposition ; but generally they are of the nature 
of local or general vascular fulness, or some disorder of secretion, or of 
the nervous system, arising from disturbances in the circulation. As 
examples, may be named — congestion of the brain, apoplexy, congestion 
of the liver, various hemorrhages and inflammations, gout, epilepsy, 
palsy, hysteria, hypochondriasis, mania, &c. 

The suppression or too rapid removal of some cutaneous eruptions 
may be appended to this class. The diseases which it excites are some- 
times inflammatory or profluvial, as gout, rheumatism, diarrhoea, &c. ; 
sometimes more nervous, as chorea, epilepsy, asthma, dyspepsia, hys- 
teria, &c. 



70 EXCITING CA.USES OF DISEASE. 

70 (8). Defective cleanliness^ ventilation^ and drainage, — Much of the 
pernicious influence exercised hj these causes might be referred to the 
last head ; for there are few kinds of filth more offensive, few mephitic 
gases more foul, and few descriptions of offal more abominable than those 
that are excreted from the animal body itself. And if, as we have seen, 
such matters are so injurious when not sufficiently eliminated out of the 
body, it is not surprising that they continue to be noxious, and may be- 
come causes of disease after they have been evacuated, if proper means 
be not taken to remove them. The necessity of self-purification is il- 
lustrated by the instinctive habits of many animals and birds, which 
take much pains to cleanse themselves and their young, and in many 
instances, carefully remove excrements from their nests and habitations. 
Even plants are supposed by some botanists to exhibit a like provision 
for preservation against self-poisoning, in the constant spreading of their 
roots into new soil, uncontaminated by their own excreted matter. Yet, 
with strange disregard of all instinctive feelings, and indolent neglect 
of the plainest dictates of reason, human beings are found continually 
exposing themselves to the influence of their own accumulated filth, 
until disease is engendered and aggravated into pestilence, and the rate 
of mortality is doubled or tripled in the population.^ 

Although the three particulars, neglect of cleanliness, imperfect ven- 
tilation, arid defective drainage, operate much in the same ways, and 
are very commonly combined, yet, with a view to suggest remedial 
means, it will be useful to consider briefly the modes in which each is 
known to excite disease. 

71 (a). Filth accumulated on the surface^ consists of the inspissated 
matter of perspiration, together with any extraneous dust or dirt to 
which the individual may be exposed. The sweat is peculiarly rank 
and offensive in some persons, especially when accumulated during much 
muscular exertion ; and in some parts, as in the axillae, and perineum, 
and between the toes, is combined with an odorous principle, the dis- 
gusting character of which seems to be intended by nature to suggest 
the necessity of frequent ablutions ; yet how many, and these not con- 
fined to the lowest ranks, are " content to live in dirt and stink," and 
often eventually to pay the penalty of their filthiness in various cutane- 
ous diseases which are thereby induced ! In young children, in females, 
and in many aged persons, the urine dispersed in the vicinity of the 
secreting orifice becomes an additional cause of irritation and offence. 

* Every practitioner of experience has encountered many proofs of the potency of these 
causes, in generating and aggravating disease ; and the profession and public have a most 
valuable collection of evidence on this point, in the following official Reports: — 

Report from the Poor Law Commissioners on the Sanitary Condition of the Laboring 
Classes. 1842. By E. Chadwick, Esq. 

Supplementary Report of the Practice of Interment in Towns. 1843. By E. Chadwick, 
Esq. 

First Report of Commissioners on the State of Large Towns and Populous Districts. 
2 vols. 1844. 

Second Report of ditto. 2 vols. 1845. 

A brief but comprehensive abstract of these Reports may be found in a small pamphlet, 
entitled Letters on the Unhealthy Condition of the Lower Class of Dwellings, &c., by the 
Rev. Charles Girdlestoue. 1845, Longman and Co. 



DEFECTIVE VENTILATION. 71 

The accumulation of filth on the surface farther favors the propagation 
of vermin and of contagious diseases, especially the itch, from which 
few of the "mighty unwashed," are totally free. It also impedes 
free perspiration, and thus favors the production of rheumatism and 
diseases of the urinary organs, and others which sympathize with the 
skin. Neglect of cleanliness in clothes and dwellings, if not equally 
injurious by direct contact with the body, becomes hurtful by contami- 
nating the air. 

[Mortality is invariably commensurate with the filth and destitution 
of the inhabitants, and the impurity of their abodes. — C] 

72 [h). Defective ventilation^ or insufiicient change of the air of 
dwellings, might be considered to readily suggest its proper remedy by 
the feeling of suffocation induced ; but it is not such a deficiency of 
oxygen, or excess of carbonic acid, as induces a stifling sensation, that 
does most harm ; it is rather the scanty supply of fresh air that stints 
the vital processes without suddenly disturbing them ; and the gradual 
accumulation of foul effluvia that slowly poisons, without exciting alarm. 
Persons are gradually brought to endure without complaint the impure 
air of a close room, which, to any one entering it from the open atmo- 
sphere, seems quite suffocating. ' Thus, in the habitations of the poor, 
especially in densely populated towns, it is not rare to find ten or fif- 
teen crowded together in one small room, without any other supply of 
air than that which comes through chinks of the floor or window, or 
when the door is accidentally open. Among this class, the dread of 
cold prevails much more than the desire for fresh air ; and except in 
the height of summer, the solitary window may be rarely opened ; and 
during the night, when the greatest number are collected together, 
every opening is kept carefully closed. During the winter, the same 
plan is pursued ; but then, if there be any fire in the hearth, it will 
insure a greater amount of ventilation. 

[A powerful exciting cause of disease is the respiration of air charged 
with exhalations from the pulmonary and cutaneous surfaces ; by which 
means the oxidizing depuratory processes are interfered with, and an 
accumulation of putrescent matter in the system takes place. It contri- 
butes to the propagation of the so-called zymotic diseases in a great degree. 
The cholera epidemic in England, in the autumn of 1849. abounded in 
proofs of this statement, as will be seen on reference to the late " Report 
of the General Board of Health." A striking illustration of the effects 
of over-croivding took place in the town of Taunton, in England, towards 
the close of the epidemic in 1849. This, a town of 16,000 inhabitants, 
with the exception of a good deal of diarrhoea, had remained tolerably 
exempt. Suddenly, a violent attack of the pestilence took place in the 
workhouse. In the course of one week, out of 276 inmates, 60, or nearly 
22 per cent, were swept away. Now, what was the condition of the 
workhouse ? It is described by Dr. Sutherland as being low, badly 
drained, and badly ventilated ; there were numerous nuisances within 
the walls, and the inmates had insufficient space allowed them, and per- 
sonal cleanliness was neglected. The medical attendant had, previous 
to the invasion of the epidemic, called the attention of the Board of 



72 EXCITING CAUSES OF DISEASE. 

Guardians to the defective arrangements of the house. '* It is very 
subject," he said, "to measles, scarlet fever, typhus, dysentery, and 
scurvy." He complained of the closeness and offensiveness of the 
■wards at night, and considered that the space allowed each inmate was 
not above two-thirds of what was requisite for safety. But the stress 
of the disease fell upon the girls' school-room. Out of 67, one-half 
were attacked, and as many as 25 died. Dr. Sutherland tells us, 
that "the greatest degree of overcrowding existed in the girls' 
school-room. In this miserable place were huddled together 67 chil- 
dren, with about 68 cubic feet of air to each. Whilst the pestilence 
was raging in the workhouse, whilst no actual case occurred in the 
town, it is a remarkable and instructive fact, that not a solitary case of 
even diarrhoea occurred in the jail. Each cell contained from 800 to 
900 cubic feet and upwards of air, besides being systematically ven- 
tilated and warmed to maintain an even temperature during the twenty- 
four hours, and attention to personal cleanliness was strictly enforced. 
Few opportunities occur, well remarks Dr. Sutherland, such as those 
afforded by the instance before us, of testing the truth of the princi- 
ples of preventive science. 

There exist numerous other emphatic observations on the effects of 
overcrowding, in exciting a virulent development of the choleraic poison 
during the epidemic in England in 1849, and the writings of the East 
India practitioners abound with interesting examples. Mr. Kellie, one 
of the most intelligent and experienced of them, says : — 

" The disease commits its greatest ravages in crowded, ill-ventilated 
barracks, bazaars, densely populated towns — particularly those sur- 
rounded by walls — crowded school-rooms, native huts, into which there 
is but one opening, and that closed at night. "Whole families are some- 
times swept away from exposure to this exciting cause." The same 
writer says, that " at Juggernaut it is an annual visitant. The town of 
Pooree contains 35,000 inhabitants, and the number of pilgrims some- 
times amounts to 150,000. The inhabitants are usually quite healthy 
before the occurrence of the festival, which takes place in June or July. 
But immediately on the arrival of the pilgrims, and when the lodging- 
houses are literally crammed with inmates, cholera suddenly breaks out, 
and in the space of a few days hundreds are cut off. This, he adds, is 
not an occasional or incidental occurrence ; it is an invariable one ; and 
the disease which has thus been generated, as suddenly disappears on 
the dispersion of the crowd." Similar testimony is adduced by Mr. 
Thorn, in his account of the dreadful outburst of cholera at Kurrachee, 
in the summer of 1846. Another singular and striking example of the 
effects of overcrowding, and showing their dependence upon a very slight 
change of circumstances, has been furnished by the late Baron Dupuy- 
tren. The usual number of patients in his ward in the Hotel Dieu at 
Paris, was two hundred, and then there was no unpleasant odor, nor 
any sign of infectious disease ; but no sooner had the number increased 
to two hundred and twenty or more, than a peculiar fetor became appa- 
rent, and many of the patieiits fell victims to hospital gangrene and 
adynamic fevers. 

It was found during the cholera epidemic of 1849, in England, that 



DEFECTIVE VENTILATION. 73 

the spots -where fever T\-as most common were precisely those where the 
cholera visitation was most general and severe; the latter appearing 
not only in the same streets and the same houses, but even in the same 
rooms which had been visited by typhusJ — C] 

The habitual want of pure air especially exercises an unfavorable in- 
fluence on the state of the blood, and the functions of circulation and 
nutrition, causing pallidity of the surface, poorness of blood, imperfect 
development of the fibrous principle, which, instead of contributing to 
the nourishment of the muscles, degenerates into scrofulous or tubercu- 
lous matter, the deposition of which in the internal organs or glands is 
favored by the weakness of the circulation. Exercise may in some 
degree counteract this effect of impure air ; thus Dr. Guy found that 
in the close workshops of a printing establishment, the compositors, 
whose employment requires no exertion, fall victims to phthisis in the 
proportion of 44 to 31J per cent, of the pressmen, who, while breath- 
ing the same air, use active bodily efforts. This difference is quite 
intelligible when it is remembered that active exercise, by increasing 
and extending the force of the circulation, tends to remove congestions, 
to promote excretion, and by the activity of the respiratory function, 
enlivens and purifies the condition of the blood. Similar exercise in 
pure air would have much more salutary effects, the deaths from the 
same cause in out-door laborers not exceeding 25 per cent. 

Insufficient ventilation is by no means confined to the dwellings of 
the poor. In modern days, when workmanship of houses is more com- 
plete than it was in olden times, there are no longer the latticed casements, 
chinky floors, ill-fitted doors, and above all the roaring pile in the spacious 
hearth, that supplied abundant ventilation to the houses of our fore- 
fathers. Now, in proportion as houses are "well-built," every crevice is 
so thoroughly stopped, that our rooms, when closed, are wellnigh air- 
tight, and their occupiers are inclosed in an atmosphere which is dete- 
riorating in proportion to the number assembled. Add to this the 
vitiating effect of artificial lights, and of fires, the smoke of which may 
not freely escape for want of a due supply of air, and it will appear 
how modern houses often comprise the conditions calculated to produce 
this cause of disease. In public offices, schools, hospitals, churches, 
chapels, theatres, and other places w^here great numbers are collected 
together, the cause is still more fully in operation ; and it is quite cer- 
tain that not only is the public health much injured thereby, but much of 
the useful or agreeable objects of such assemblies is defeated through 
the discomfort produced by the closeness and foulness of the air. 

' ["Whilst these pages are passing through the press, another very strong and incontestable 
instance of the effects of overcrowding in the production of epidemic disease, has been 
presented. During the months of January, February, and March, 1853, Typhoid Fever 
has prevailed to a great and alarming extent in Paris. A late number of the Gazette des 
Hopitaux thus accounts for this sudden and severe visitation : In the latter part of the 
year there was a large arrival in the capital, of work-people ; from the demolition of 
several of the most densely populated quarters inhabited by this class, on account of the 
improvements, they accumulated in other parts of the city. Work became suddenly 
interrupted on the occurrence of the severe weather ; and the dwellings of the laborers, 
■which were dirty and ill-ventilated, became over-crowded ; and more than two-thirds, 
perhaps three-fourths of those attacked, lived in these lodging-houses [garnis). — C] 



74 EXCITING CAUSES OF DISEASE. 

The ill effects of deficient ventilation are increased by heat and moist- 
ure; the former operating not only by increasing the animal exhala- 
tions, but also by rarefying the air, and thus reducing the amount of 
oxygen in a given bulk ; moisture probably acts in a degree in like 
manner, but also, as I conceive, by removing the difference between the 
air respired and that in the lungs which promotes that diffusion or inter- 
penetration of gases on which the access of oxygen to the vesicular 
structure of the lungs depends. For, be it remembered, the air taken 
in at each inspiration, is not enough to reach far in the tubes ; its trans- 
fer into the air-cells is accomplished by the law of diffusion of gases, 
which operates in proportion to the dissimilarity between the gases, and 
difference in amount of contained watery vapor must exemplify this 
law. 

In certain occupations, gases or vapors of a positively noxious 
quality are engendered, and augment the evils of deficient ventilation. 
Such is the case in many chemical works, slaughter-houses, and dissect- 
ing-rooms, soap, glue, and cat-gut manufactories, and in the employ- 
ments in which materials are used containing mercury, wdiite lead and 
arsenic (§ 53). The deleterious operation of effluvia arising under 
these circumstances, may be short of a directly poisonous effect, yet, 
by adding to the unwholesomeness of the atmosphere, it gradually un- 
dermines the health, and is best to be counteracted by a more eflScient 
means of ventilation. 

73 ((?). Defective drainage comprises much of the influences exer- 
cised by the preceding causes, filth and foul air ; but it includes also 
circumstances that may exceed them in pernicious operation. The soil, 
which drains from habitations, contains, in addition to excrement, dirty 
water, washings and remnants of animal and vegetable matters used as 
food, and other offal ; and all these, when mixed and stagnant, consti- 
tute the corrupting slough retained in cesspools and privies, and carried 
into sewers. The stench which these exhale, when opened, gives some 
idea of their deleterious influence ; and the fearfully poisonous nature 
of the gases which they emit, has been proved by the sudden faintness 
and sickness, nausea, vomiting, and diarrhoea, which have attacked 
persons engaged in emptying them. Instances have occurred of indi- 
viduals being speedily asphyxiated by the gases of cesspools; and 
where the result is not immediately fatal, a congestive or typhoid pneu- 
monia ensued, which passed into gangrene in the first stage. (Chomel.) 
The precise nature of the gases evolved is not fully ascertained ; but 
they obviously contain much sulphuretted and carburetted hydrogen, 
which, although known to be highly noxious, probably do not comprise 
the most deleterious part of these offensive effluvia. It is no wonder, 
then, that every ill-drained house should have a Pandora's box, ready 
to pour forth its evils whenever occasion offers ; and always oozing them 
out in degrees sufficient to impair the health of the inhabitants, and 
gradually to excite cachectic and other chronic diseases. Hence, as it 
appears in the several sanitary reports before cited, the mortality rises 
in a remarkable proportion in all those districts of towns where sewer- 
age is absent or inefficient. The worst nuisance of this description is 



EXTREMES OP TEMPERATURE. 75 

the cesspool without a drain from it ; unemptied for months or years, 
and often imperfectly covered, it continually poisons both air and water ; 
and typhoid fever, diarrhoea, cholera, dysentery, dyspepsia, inappe- 
tency, and general weakness and mal-nutrition, are results of different 
degrees of its pestiferous operation. Scarcely less injurious, and more 
insidious in its operation, because the effluvium is less offensive, is the 
untrapped drain in connection with the sewers of large towns. This 
cause of disease exists extensively in London, not only in the street 
drains, which are always open and emitting the gases of the sewer, the 
bad odor of which is perceptible in certain winds, but also in the drains 
of houses which are either intentionally or negligently left open, or are 
not air-tight from the absence of water in the traps. Nothing is more 
common than to perceive the peculiar smell of the drain on entering a 
house, and in many instances I have found that this has proceeded 
from the trap left open, or dried up, and therefore inoperative, and 
requiring. only the simplest expedient to stop the evil. When a single 
trap is open in a house, especially in the winter, when doors and win- 
dows are closed, and there is no adequate supply of air for the fires in 
the house, the foul air is drawn up from the sewer in a strong current, 
and quickly pervades the house from bottom to top, carrying with it a 
pernicious influence. It is surprising how ignorant servants and em- 
ployers and even professional men, are on this point, which so imme- 
diately concerns their health and comfort; and I have visited in many 
houses where this has seemed to be a cause of illness or impeded con- 
valescence, in low nervous fevers, bowel complaints, influenza, neuralgia, 
headaches, and other ailments. In some instances, the leakage may be 
in consequence of the inroads of rats, or the displacement of the brick- 
work of the drains. It may be useful to state that, besides by the 
smell, which is not obvious to every one, the effluvia of drains may be 
detected by the darkening of white paint, and the early spoiling of 
meat in the lower basement story of the house. 

74 (9). [The influence of seasons in predisposing to and exciting dis- 
ease is much the same as that of temperature. From the accurate and 
valuable statistics of the Registrar-General of Great Britain, it appears 
that the greatest number of deaths occurs in winter, next in spring, then 
autumn, and finally summer ; and from the imperfect statistics of several 
of our States, the mortality would appear, especially as far as the 
Northern States are concerned, to follow the same rule. Diseases in 
the spring are said to be more acute, their symptoms to be better defined, 
their course more speedily run, their treatment more amenable, and their 
liability to relapse less. Autumnal disorders are more insidious in their 
origin, more irregular in form, more protracted, less readily cured, and 
very subject to relapse. At this season all diseases of malarious origin 
prevail in warm climates; and in more temperate countries, disorders of 
the digestive system are common ; — excited by the violent and sudden 
alterations of temperature, between day and night, and the imprudent 
and immoderate use of fruit. — C] Of all the exciting causes of disease, 
there is none so common as temperature in extremes, or in sudden- tran- 
sitions ; cold, heat, and sudden transitions from cold to hot, or hot to 



76 EXCITING CAUSES OF DISEASE. 

cold. Both heat and cold have different modes of operation, and cause 
disease in different ways. 

Extreme heat and extreme cold are directly destructive to life. Heat 
above 180° coagulates the albumen of the blood, and thus obstructs the 
bloodvessels, and may cause other chemical changes of a disorganizing 
nature (§ 53) ; a part that has been raised to this temperature, therefore, 
necessarily dies ; it cannot live again. It is true that we occasionally 
see boiling water at 212°, boiling oil at 600°, and redhot iron at 1000°, 
produce no other effect than violent inflammation and blistering of a part ; 
but that is because these bodies have been applied for too short a time 
to do more than violently stimulate the part, not time enough to raise it 
to the decomposing temperature; a few seconds more, and the part would 
be killed. 

Cold below 32° freezes the water of the fluids ; and as it destroys the 
life of tender plants, so it -kills parts of animals, whether by the expan- 
sion of the ice injuring the delicate organization (Sir B. Brodie), or 
whether from the mere stoppage of the circulation, or other cause, is 
unknown. The part may be afterwards separated from the living parts 
by a vital process of inflammation and sloughing. 

75. A disorganizing degree of heat, extensively applied, acts like a 
violent mechanical injury — such as tearing off or crushing a limb (§ 52). 
It directly depresses all the functions ; the pulse becomes very weak, 
frequent, and sometimes irregular ; the muscular strength almost annihi- 
lated, and consciousness may be nearly or quite suspended. In this 
state, notwithstanding the stimulant properties of heat, and the inflam- 
mation which it generally excites, patients require stimulants, and they 
often die in a state of complete collapse, without any rallying or reac- 
tion. Extreme cold, also, if for some time applied to the whole body, 
depresses and paralyzes all its powers, even that of generating heat, and, 
therefore, of resisting cold. Sir Astley Cooper observed, that on plung- 
ing kittens into ice-cold water, the arterial blood did not become venous 
in the veins ; and Chossat found, in animals killed by cold, arterial blood 
in the left cavities of the heart. From a similar cause, the limbs become 
benumbed by extreme or continued cold ; thus persons are drowned 
in cold weather much more speedily than in warm. With less intense 
degrees of cold, on the other hand, which do not destroy the vital pro- 
cesses, more oxygen is absorbed, more carbonic acid formed, and heat 
generated, which are the means by which animals resist cold. 

76. Heat which is insufficient to decompose, is directly stimulant. It 
excites the function of parts, and when generally applied, induces a state 
of fever. Thus when a person is in a vapor-bath, or hot-air bath, the 
pulse quickens, the whole surface becomes red, full, and hot ; there may 
be throbbing and pain in the temples, and a feeling of feverish oppres- 
sion, until a sweat breaks out, which relieves the superficial tension and 
fulness, and soon reduces the increased heat. Similar results may en- 
sue from confinement in overheated rooms ; and if there be any tendency 
to local congestion or inflammation, particularly in the head, this excite- 
ment may be enough to produce it. The continuance of heat enervates, 
reduces the strength and appetite, and may excite a feverish state, Avith 
disorder of the liver. The oppressed breathing which is often felt in 



COLD — MODES OF ACTIO^T. 77 

heated rooms may, according to the view of Liebig, be ascribed to the 
smaller amount of oxygen in the air rarefied by the heat ; but it is pro- 
bable that this is not the only cause. 

A more partial exposure of the body to heat may produce still more 
disordering effects, if the part overheated be capable of suffering from 
the excitement. Thus solar or artificial heat to the head may cause 
severe headache, apoplexy, or inflammation of the brain. Heat to the 
spine, as on sitting with the back near a large fire, is very apt to cause 
sickness and faintness, and, if continued, may induce convulsions. More 
local inflammations, as of the eye, ear, and skin, are frequently caused 
by exposure of the parts to heat. Gout may sometimes be excited in 
the feet by the same stimulus, and this is often attempted purposely. 

77. Cold, on the other hand, is directly sedative. It contracts tissues 
and vessels, especially the arteries, and thus at first renders parts pale 
and shrunk. In persons of feeble circulation, after bathing, the fingers 
are sometimes quite bloodless and numb from this cause; the cold having 
quite closed up the arteries.^ But cold also retards the passage of the 
blood in the capillaries; the viscidity of the liquor sanguinis seems to be 
increased ; globules stick to the sides, or move but slowly, and the part 
soon becomes purple or blue, from the congestion of blood in it. This 
purple color is chiefly seen in parts much exposed, and where the blood 
habitually enters with freedom, as the cheeks, ears, nose, and hands. 
There is also much internal congestion from the intropulsive operation 
of the cold — that is, the external- parts being constricted and obstructed, 
blood accumulates more in internal parts, and the heart's force is more 
expended on these. This may in part account for the degree of stupor 
and ultimate insensibility into which persons exposed to extreme cold 
are apt to fall. In some such cases, there has been a flow of blood from 
the nostrils or ears ; the stupor has continued for hours after the heat and 
circulation have been restored ; and, in fatal cases, much serous effusion 
has been found in the brain.^ 

78. Hitherto, we have considered the immediate operation of cold (§§ 
74, 77). But its indirect effects are more commonly known : these are, 
reaction, irritation, inflammation, and their consequences ; and they will 
be more manifest where the cold has been partial, and the strength of 
the circulation generally not reduced. Thus, after a part has been ex- 
posed to severe cold, when restored to warmth, it becomes the seat of 
increased flow of blood, which causes redness, pain, and more heat ; and 
various forms of inflammation may ensue, generally modified by the 
specific effect which the previous cold has exercised on the vessels and 
nerves ; varying also with the strength of the general circulation. Thus, 
as the indirect effects of cold in a part, we may have chilblain, gangren- 
ous or erysipelatous inflammation, and paralysis, or altered sensation. 

' A similar effect may be seen under the microscope, on applying ice-cold water to the 
frog's web ; the arteries contract to obliteration. This is contrary to the assertion of Poi- 
seuille. (See my Gulstonian Lectures, Med. Gaz. July 16, 1841, p. 639.) It must be re- 
marked, that the elementary action of cold on the arteries is strictly stimulant, exciting 
their vital property of contraction ; but its operation on textures and organs is sedative, 
because it impairs the circulation which supports their functions. So, too, we have found 
that, where it reaches the heart, it paralyzes its powers (§ 74). 

2 Kellie, Ed. Med. Journal, vol. i. p. 30-i, quoted by Dr. Alison. 



78 EXCITING CAUSES OF DISEASE. 

As much of the disease in these partial eifects of cold, arises from the 
violence of the reaction and inflammation, and this depends on the sud- 
den return of heat and circulation in the part, it becomes an obvious in- 
dication, for frost-bitten limbs, to retard this return by cold applications. 
But Dr. Alison well remarks, that this precaution is not needed, where 
the sedative eifects of cold have been more general ; here warmth and 
stimulants may be used freely, for there is no fear of partial injurious 
reaction. 

79. We have hitherto chiefly considered the manner in which cold 
causes disorder in the parts to which it is applied ; but this is not the 
most common mode in which cold excites disease. A person gets his 
feet wet, stands in a draught of cold air, or is exposed to cold when in- 
sufiiciently clothed ; he afterwards becomes diseased — not in the feet, 
or the parts chilled, but in some internal part. He gets a sore throat, 
a " cold in the head" or chest, an inflammation of the lungs, a rheuma- 
tism in the limbs, a looseness of the bowels, a catarrh of the bladder, or 
any other disease to which he may be predisposed (§ 14). Now how 
does the external cold cause internal disease ? How is the efiect trans- 
ferred from external to internal parts ? 

Dr. Alison supposes that the cold operates chiefly on the nerves, and 
that the sensation which it excites is conveyed also by the nerves to the 
internal organs, where its morbid eff*ects become manifest. But it must 
be objected that the morbific efiects of cold are by no means proportioned 
to the sensation, or known nervous impression, which it excites. A 
person may have his limbs aching and benumbed with general cold ; yet 
internal disease does not result. But if he has been exerting himself, is 
perspiring, and then gets his feet wet, or is otherwise exposed to cold, 
especially partial, without continuing his exercise, although he may 
scarcely /eeZ the cold, yet he will be pretty sure to catch cold, and to 
exhibit some one or other of its internal morbid effects. 

It would seem more probable, therefore, that external cold excites in- 
ternal disease by deranging the circulation, particularly that in the capil- 
laries. Cold checks the external secretion, the perspiration; it constricts 
and obstructs the vessels of the surface (§ 77), and must thus throw more 
blood inwardly, so that internal congestions are produced — these internal 
congestions impair the functions of the affected organs, especially those 
concerned in excretion (§ 68), and in other ways lay the foundation of 
disease. This intropulsive effect of cold will take place more readily, 
and to a greater extent, in proportion to the weakness or sluggishness 
of the capillary circulation. This may be weak naturally (§ 20) ; in 
this case, there is a constant liability to "take cold." Or it may be weak 
and relaxed from previous excitement, during fatigue (§§ 23, 24), or dur- 
ing sleep. Hence persons are more apt to catch cold after being in a 
hot room, after exertion, or when asleep. On the other hand, the in- 
jurious effect of cold is lessened or prevented by a vigorous state of the 
capillary circulation, w^hether that vigor be natural, or excited by con- 
tinued exertion, stimulating drinks, or by febrile excitement (§ 17). 

On this view, we can understand why partial, but continued cold, such 
as from draughts of cold air, wearing damp clothes, standing on cold 
stones, and the like, should be particularly injurious, even when the 



COLD — MODES OF ACTION. 79 

sensation of cold excited is not great. Such causes of cold, acting long on 
the same part, more completely constrict its vessels, check its secretions; 
thus more surely injure the balance of the circulation, and by throwing 
a corresponding amount of congestion inwardly, fix it in some part pre- 
disposed to disease (§ 14). 

When a person has thus taken cold, which he knows by general sen- 
sation of coldness and weak circulation, rather than by any feelings in 
the part chilled, powerful measures, which tend to restore the balance of 
the circulation, such as violent exertion, a hot or vapor bath, or stimu- 
lant drinks, may often yet prevent the further progress of disease. The 
general application of cold, if not long continued, is less injurious than 
that whieh is partial, both because it disturbs less the balance of the cir- 
culation, and because also it supplies the lungs with denser air, and 
therefore more oxygen ; and its impression on the nerves of the face and 
chest excites more energetic respiratory movements, which maintain the 
heat and the vigor of the circulation. Healthy persons rarely take cold 
when travelling on the top of a coach, or in a perfectly open carriage, 
but they frequently suffer in a close carriage partially open. 

80. Susceptibility to the morbid effects of cold is to be diminished by 
means which invigorate the capillary circulation, especially those which 
promote that process of reaction by which cold is naturally resisted. 
Now nothing tends to increase this more than sudden artificial applica- 
tions of cold, as by cold bathing or sponging, followed by friction, exer- 
cise, heat, or stimulant applications, which promote the reaction (§ 16). 
The great art in usefully applying cold with these intentions, consists in 
using the cold in such manner and degree, and having the body in such 
a state before and after the application, that the reaction or glow, which 
is the sign of vigor in the capillary circulation, shall be most fully pro- 
duced. If, on the other hand, the cold be applied too long, or when 
the body is exhausted by fatigue, exertion, or other cause (§ 20), or is 
naturally too weak, depressing effects of cold will continue ; there will 
be little or no reaction, and the sensations of languor and chilliness 
show that the cold has been injurious instead of beneficial. The addi- 
tion of salt to the water of baths, gives it a stimulant property which 
promotes reaction, and a similar influence results from the force or shock 
with which the water is applied. This shock excites deep and forcible 
respirations through an impression on the incident nerves ; and these 
are probably the efficient cause of the process of reaction which follows. 

The reaction which follows the judicious use of cold as a therapeutic 
agent, may prove serviceable, not only in resisting the farther influence 
of cold, but also to remove congestions and irregularities in the circula- 
tion from other causes, and to excite in the capillaries and secernents 
new actions, which may supersede those of disease. It is thus that the 
" water cure" of Preissnitz chiefly operates ; and although too powerful 
an agent to be entrusted to unskilled and unscientific hands, it promises 
to become a valuable addition to the means of combating diseases, par- 
ticularly of a chronic kind. 

81. In the preceding remarks on cold, it must be borne in mind that 
the term cold is applied relatively, not absolutely ; cold is not a fixed 
temperature or range of temperature ; but something considerably below 



80 EXCITING CAUSES OF DISEASE. 

the temperature of the body. Thus, a body that has been warmed 
throughout to a heat of 98^, and kept in an excited state by that- tem- 
perature, would suffer from a draught of air at 70°, which would be cold 
to the body, and produce the physiological and pathological effects of 
cold. But if the body had not been previously warmed, so that the 
temperature of most parts of the surface might not exceed 85°, or if, 
although lately warmed, the energies of the body had not been exhausted 
by it, then air at 70° would feel pleasant, and produce none of the effects 
of cold. This is one of many facts which distinguish vital from physical 
properties. Physical or chemical properties are generally affected by 
fixed temperatures, independent of previous circumstances ; but vital pro- 
perties are variously affected through that power of adaptation by which 
they are enabled to maintain the same function in varying external cir- 
cumstances. 

It is thus that atmospheric changes in variable climates are fertile 
causes of disease. In this country, on a sudden change of wind, the tem- 
perature sometimes falls 15° or 20° in the course of a day, and without 
any peculiar exposure, the body may become so chilled by the change, 
as to suffer to a degree amounting to disease. Internal congestions are the 
common result, but the seat of congestion and disorder will vary accord- 
ing to the predisposition. Thus, after the heat of summer, the organs 
most apt to suffer are the liver and abdominal viscera, which are disposed 
to disorder by previous excitement (§ 25) ; on the other hand, in the 
spring after the winter cold, the lungs and air-passages are more prone 
to derangement (§ 26). 



SECTION lY. 

II. Non-cognizable Agents. 

We now proceed to notice those causes of disease, the existence of 
which is inferred only from the fact that disease prevails under certain 
circumstances not well explained, unless we assume that causes do ex- 
ist (§ 12), although we cannot prove their existence in any other way 
(§ 53). These comprise the endemic^ epidemic, and infectious causes of 
disease. In the reports of the Registrar- General, they are termed zy- 
motic {^vfir;, a ferment), but inasmuch as this epithet involves an hypo- 
thetical signification of their mode of action, it does not seem expedient 
to adopt it here. 

I. ENDEMIC CAUSES. 

82. Persons living in a marshy district are often afflicted by a disease 
called ague^ which does not attack those inhabiting dry lands. Again, 
the inhabitants of certain deep valleys are often affected with the swell- 
ing in the neck called bronchocele, or goitre ; the neighboring mount- 
aineers are not so affected ; and when those from below remove their 



ENDEMIC CAUSES. 8L 

residence to the mountains, they often lose the disease. These are 
instances of diseases which may be said to dwell among the residents 
in particular spots ; hence they are called endemic^ in the people {sv 

In some cases, much doubt still hangs over the precise source of en- 
demic influence : some supposing it to be in the water, others in emana- 
tions from the soil ; but this doubt does not apply to the cause of agues, 
intermittent and remittent fevers, which have been clearly traced to 
effluvia from marshes, jungles, rice grounds, kc. It has been found that 
when the wind blows across these marshes, the disease appears chiefly 
in persons residing to leeward of them, and not to windward ; and it has 
been abundantly proved, that when the marshes are drained the ague 
ceases. From these and similar facts, it is concluded that the cause of 
the ague is an effluvium^ miasm, malaria, or bad air; an aerial poison, 
which is supposed to 1^ inhaled with the breath, and absorbed into the 
system. 

83. The true nature of marsh malaria has not been determined. It 
has never been detected by chemical analysis. Professor Daniel con- 
jectured that the malaria causing the destructive endemic fevers of 
Western Africa, might be sulphuretted hydrogen evolved from the sea- 
water by the decomposing vegetable matter brought down by the rivers; 
but I am informed by Dr. D. B. Reid, that experiments made in the 
late unfortunate expedition to the Niger, have negatived this notion. 
[Dr. D. Pereira Gardner reached the same conclusion as the late Prof. 
Daniel, as to the result of experiments on the air of malarious regions.^ 
These views have been, however, entirely disproved by Drs. McWilliam^ 
and Morris Pritchett, who have shown that free sulphuretted hydrogen 
does not exist in the waters of the Nile — the locality from which the 
water with which Prof. D. experimented was obtained ; and that which 
was detected in the specimens sent to England and there examined, was 
generated on the passage, by the decomposition of the contents of the 
bottles. — C] The microscope, rather than chemical analysis, may be 
expected to discover the nature of malaria. 

Although hitherto unknown in its nature, some knowledge of the 
general properties of marsh malaria has been obtained through its mor- 
bific efi'ects. It seems to be heavier than air; for persons occupying 
a ground floor suS'er more than those li\'ing in upper apartments. Water 
seems to absorb or destroy it, for persons on board ship, or on an oppo- 
site side of a lake, are not aifected; whilst at a greater distance, a favor- 
able wind will convey the pernicious influence over land. A damp state 
of the air, however, favors its production; good fires in a house give 
marked protection to the inmates. It seems to be attracted by trees ; 
for the vicinity of trees is doubly dangerous, whilst places beyond trees 
are more free from its efi'ects than others at the same distance. 

[Of the intimate nature and physical properties of marsh miasm, we 
know nothing. The vapors of the putrid waters of Fuentes, of the rice 
fields of Carolina and Lombardy, and of the Campagna, near Rome, 

1 [Am. .Joxirn. Med. Sciences, April, 1843.] 

2 [Medical History of the Expedition to the Niger, &c. London, 1843.] 



82 EXCITING CAUSES OF DISEASE. 

have been found identical in composition with the most salubrious air, on 
chemical analysis. But though ignorant of the active principle of paludal 
miasm we know many of the laws which govern its operation. It is 
in greatest concentration near the surface of the earth. We can trace 
its operation in a definite line of progress, and can observe it arrested 
by material impediments, as lines of buildings or trees. It has difficulty 
in crossing streams. Heat is its great evolver ; moisture its chief vehicle. 
It differs from the animal or morbid poisons, in its longer periods of 
latency, and in the slowly progressive character of the functional and 
textural changes which it produces in the economy. It does not seem 
to possess those special affinities for certain textures, as shown by the 
morbid poisons ; it confers no subsequent immunity ; it does not multiply 
or reproduce itself in the system ; nor are its effects capable of propaga- 
tion from one person to another. That it is a material poison capable 
of effecting its entry in the blood is certain. It is soluble, for it may 
affect the foetus in utero. (Simon.) — C] 

84. The chief points known with regard to the source of malaria, are, 
that it arises from the operation of the sun's heat on marshy ground, or 
on the banks or deltas of tideless rivers, after evaporation has proceeded 
to some extent ; putrefaction of organic matter not being an essential 
part of the process.^ The virulence of the malaria, as shown in the 
severity of the disease excited, and in the number which it affects, seems 
to bear some proportion to the heat which has led to its development. 
Thus the ague of this country, the pernicious intermittent of Italy, and 
the malignant intermittent of Western Africa and the West Indies, seem 
to arise from similar endemic causes, but differing in their virulence ac- 
cording to the degree of heat. A certain amount of moisture is, how- 
ever, required; for a very dry season, which desiccates a marsh, stops 
the malaria ; and the deposit of the evening dew always favors its pro- 
duction (§ 83). Again, excess of moisture checks its development, so 
that a very wet season, as well as a very dry one, may render a marsh 
less unhealthy (§ 83). Extreme heat will not, however, diminish the 
malaria from the banks of rivers, since portions of these are never 
dry. For a similar reason, all the low shores of the Mediterranean are 
always malarious at the commencement of hot weather ; the absence of 
a tide preventing that frequent salt washing and drainage which purifies 
other European shores. 

It is not only marshy or low grounds that engender malaria, although 
these are the situations commonly most favorable for its production. All 
that seems to be requisite is the continued operation of the sun's heat 
on moisture stagnant at or near the surface of the ground. I know 
instances in which ague has attacked persons living on a height of 
mountain limestone, forming a small table-land below greater heights. 
So also some swampy lands are not malarious, particularly peat bogs, 
which show a remarkable exemption from decomposition and effluvia of 
all kinds. 

85. The morbid effects of marsh miasms are several ; intermittent and 

' Chisliolm and Ferguson, Ed. Med. and Surg. Journ. vol. vi. ; Trans. Roy. Soc. Edin. 
vol. ix. 



EPIDEMIC CAUSES. 83 

remittent fevers of various types are the most remarkable of these, and 
they particularly affect the new residents ; but the older inhabitants suf- 
fer from diseases of the liver and spleen, nervous affections, rheumatisms, 
dropsy, and cachectic complaints, and are generally short-lived. The 
first operation of malarious poison seems to be on the quality and distri- 
bution of the blood, which in the worst cases becomes speedily darker 
in color and otherwise altered, and accumulates to an extraordinary 
amount in internal organs, vfhere it suffers still further from its stagna- 
tion and want of purification by the ordinary excretions. The fit of 
an ague is the reaction (§ 16) of the vital powers against this decom- 
posing and cumulative influence of the poison on the blood ; and if the 
vital powers are strong, and the dose of the poison not overwhelming, 
the fit successfully removes the internal congestions, and partially re- 
stores the purity of the blood by an increase of the excretions ; but the 
poison, being still in the system, reproduces similar effects after a longer 
or shorter interval. 

One of the most remarkable characters in the disease resulting from 
malaria, is the periodicity of their attacks, and the diminution or cessa- 
tion of the symptoms in the interval. This is probably due to the alter- 
nate accumulation of the malarious influence in the body and the reaction 
of the vital powers against it. 

86. There can be little doubt that there are different kinds of malaria 
besides that which causes intermittent and remittent fever (§§ 80, 81). 
Thus yellow fever and plague are endemic diseases, probably arising 
from aerial poisons. The propagation and mortality of the latter, per- 
haps its very existence, are very much to be ascribed to the filth and 
impurities of the towns where it prevails. These are cognizable causes, 
the operation of which in exciting and predisposing to disease has been 
already noticed (§§ 70-73, § 22). 

Some other epidemic diseases can be traced to other cognizable causes ; 
as the Guinea-worm, to drinking water containing its ova ; the pellagra 
of northern Italy, and the plica of Poland, to neglect of cleanlinesSj 
and unhealthy modes of living. 



II. EPIDEMIC CAUSES. 

87. There is another class of diseases, which, in their affecting many 
persons in the same place and at the same time, resemble the endemic 
(§ 81). But they differ in this respect, that they do not regularly return 
at stated seasons (§ 84), nor are they confined to particular localities 
(§ 82), although they infest some more than others ; but they attack a 
whole district, a whole country — nay, almost a whole hemisphere — 
within a very short time ; often coming on without obvious cause; pre- 
vailing for some time, then disappearing for an uncertain period ; per- 
haps recurring within a few months, or years, or not within the memory 
of man. These are called epidemics (frtt§J7,uof), like a blight or per- 
nicious influence blowing on the people ; and therefore affecting a whole 
country at once. 

88. The cause of these diseases is supposed to be something in the 



84 EXCITING CAUSES OF DISEASE. 

atmosphere ; because the atmosphere is the only thing common to all 
the places so affected ; but the nature of the cause is not known. It is 
true that some diseases, which seem to prevail epidemically, may be 
traced to the cognizable qualities, cold, heat, dryness, and moisture of 
the air (§ 74, et seq.). Thus diseases excited by cold sometimes pre- 
vail, like an epidemic, in the winter ; those by heat, in the summer ; 
catarrhs and quinsies abound in cold damp w^eather ; croup and rheuma- 
tism become common during the prevalence of a cold east wind, in the 
spring ; diarrhoea and dysentery are rife in the fruit season of the autumn. 
Others, again, such as dysenteries, fevers, scurvies, &c., have in some 
instances obviously arisen from deficient or contaminated food, bad w^ater, 
or some distinctly cognizable cause (§§ 60, 70, et seq.). And as these 
causes belong to the class of cognizable agents before noticed (§ 52, et 
seq.), it is unnecessary to advert to them here. [The influence of local 
agencies on the development and virulence of contagious disorders is 
universally admitted. We need go no farther for convincing proofs 
than the history of the recent cholera pestilence ; the concurrent evidence 
of medical men, in every part of the world visited by this fearful pest, 
establishes inevitably the fact. The most salutary and efficient results, 
invariably resulted from proper sanitary measures. The celebrated Dr. 
Rush wrote, seventy years ago : " To all natural evil, the Author of nature 
has kindly prepared an antidote. Pestilential fevers furnish no excep- 
tion to this remark. The means of preventing them are as much under 
the power of human reason and industry, as the means of preventing 
the evils of lightning and common fire." All medical experience con- 
firms the accuracy of this statement. These means should engage the 
serious attention of the physician. It is as much his duty to prevent 
disease as to cure it when once developed. He thus materially con- 
tributes to the great end and object of his mission — the saving of life ; 
the mitigation of sufi*ering ; and the consequent amelioration of the suf- 
fering of his fellow-men.— C] 

89. But there are diseases occurring epidemically without any dis- 
coverable connection with season or temperature. Thus an epidemic in- 
fluenza may come on at any season of the year, rapidly spread through 
a country, and cease as unaccountably as it began. So, too, diseases 
that are usually excited by other causes, infectious and others — such as 
typhus and scarlet fevers, measles, smallpox, erysipelas, &c. — some- 
times prevail throughout a country so generally, and often .with such 
peculiar characters, that some influence besides their common causes 
must be concerned in their sudden increase. The nature of this influ- 
ence is unknown ; but it is called epidemic (§ 87). 

90. Lastly ; various diseases, fevers, and inflammations, and almost 
all sorts of ailment, at some periods assume a remarkable character in 
common or type (as it is called) ; for example, being attended with un- 
usual weakness, or unusual excitement, or a tendency to hemorrhage. 
This is called an epidemic or prevailing diathesis, or constitution. Thus 
at uncertain times, fevers, wherever arising, and from whatever source, 
are more low, typhoid, or adynamic, than usual; at the same time, ex- 
anthcmatous diseases generally partake of the same character ; and even 
patients afl'ected with inflammations do not well bear the usual deple- 



EPIDEMIC CAUSES. 85 

tions. Of late years, this constitution has more or less prevailed, and 
may be contrasted with a period of twenty years ago, when an inflam- 
matory diathesis existed, and bloodletting was advantageously employed 
even in continued fever. 

91. It has been before stated (§ 88), that we are quite in the dark 
as to the nature of epidemic influences, or causes of disease. Many con- 
jectures have been advanced, some of them with much plausibility, but 
without any substantial support. Dr. Prout states that, shortly before 
and during the prevalence of the malignant cholera in this country, he 
noticed a small but decided increase in the average weight of the atmo- 
sphere, as if from the addition of some ponderous gas. At the same 
time, he remarked an unusual acidity in the saliva even of healthy per- 
sons, and such an absence of lithic acid from the urine, that he seems 
inclined to suppose that a disposition to form oxalic acid was referable 
to the same unknown cause which was then producing cholera (§ 60). 

92. Many analogical arguments may be adduced in favor of a favor- 
ite notion of Linn^us, that epidemic diseases are caused by animalcule 
tribes. This hypothesis [first broached by Kircher, and sanctioned by 
Linnseus — C] has been ably advocated by Dr. Holland^ and Dr. Henle,^ 
[and Dr. J. C. Xott, of Mobile.^ — C.]. Before I had seen the opinions 
of these authors, I had stated in my lectures some arguments in favor 
of this notion, which will be given under the head of infection. The 
chief facts which countenance this view, are the following : 1. Epi- 
demic diseases, in the uncertain periods and places in which their visita- 
tions occur (§ 88), resemble those of blights, or tribes of insects which 
are known to appear and disappear without evident cause. 2. Proofs 
are accumulating of the occasional existence of parasitic animals and 
plants in living animals, and in some instances as causes of disease (as 
in the case of worms and other entozoa, acari in itch, the rot-worm in 
sheep, the mycodermatous vegetations in porrigo,^ confervas in impetigo, 
aphthc'e, kc). 3. The history and symptoms of some epidemic diseases, 
such as cholera and influenza, are not inconsistent with the hypothesis 
that they are caused by the sudden development of animalcules from 
ova in the blood. But there is a total want of direct observation in 
support of this hypothesis ; and, perhaps, it may be objected against it, 
that the seasons at which epidemics sometimes appear (as cholera in 
winter) are not always those most favorable to the development of ani- 
malcule life.^ 

[This subject has been most ably handled by Professor Simon, in his 
lectures on Pathology. He observes : In sustaining this parasite theory, 
great ability has been displayed, and the facts recently ascertained, as 

* Medical Xotes and Eeflections, 1840, p. 597. 

2 Pathological Researches, British and Foreign Medical Review, April, 1840. 

3 [New Orleans Medical and Surgical Journal, 1848. — C] 

■* Gruby, Comptes Rendus, t. xiii. Bennett, Trans. Royal Soc. Edin. 1842. 

5 The prevalence of the south-east wind was observed to be particularly favorable to the 
increase both of cholera and influenza ; and I cannot but think that this had some connec- 
tion with the general tendency exhibited by the former to spread chiefly from east to west. 
Has the morbific property of this wind aught to do with the haziness of the air when it 
prevails — a haziness seen in the country remote from smoke, and quite distinct from fog? 
V> hat is this haze ? In the west of England, a hazy day in spring is called a blight. 



86 EXCITINa CAUSES OF DISEASE. 

to the connection of fermentation with infusorial and vegetable life, 
have been cleverly applied, and the evidence lately obtained regarding 
infectious disease, produced by parasitic influence in the lower animals, 
of which that curious disorder, the muscadine of the silk-worm furnishes 
the most remarkable example, has also been adduced in support of this 
opinion. The evidence on this subject varies in kind and conclusive- 
ness. But great difficulty will be experienced, I think, in accepting 
this doctrine as a perfect solution of this intricate and debatable ques- 
tion. Recognized parasitic diseases, are from first to last essentially 
local. Both in the lower animals and in man, we are familiar with many 
parasitic disorders. In addition to scabies and hydatids, where the 
cause of the disease is an animal parasite, there are others where the 
parasitic growth is vegetable. Some forms of porrigo depend on parasitic 
vegetables — mycodermata. In porrigo decalvans, there is a peculiar 
torula developed within the hair, causing baldness^ without coexisting 
disease of the scalp. Vegetable organisms have their epiphytic parasites. 
Their blights are epidemic. The minute fungi which constitute these 
diseases multiply with incredible rapidity; "frequently," says Sir Joseph 
Banks, in his paper on the Blight of Corn, "in the latter end of sum- 
mer, must the air be loaded, as it were, with this animated dust, ready 
whenever a gentle breeze, accompanied with humidity, shall give the 
signal to intrude itself within the pores of thousands of acres of corn." 
Now, wherever this " animated dust" lights, the result is local, so like that 
in animals, that a celebrated botanist has called these diseases the exan- 
themata of plants. In each pore where a sporule enters, it grows and 
multiplies ; it destroys the part ; and if there be enough of them, they 
drain, they exhaust, and they starve the organism of the plant ; their 
development is at the expense of the aifected body. In the hydatids of 
sheep we notice the same result. Now there is no analogy here with the 
results from the inoculation of smallpox or syphilis. There is a great 
difference between these phenomena and those resulting from the con- 
tamination of the human organism from the animal poisons. There the 
general or constitutional irritation occurs only when the local irritation 
is extensive ; or when the foreign parasitic bodies impoverish the blood, 
from their demands upon it ; it is developed at the quantitative expense 
of the animal or vegetable. Their effects on life are in direct propor- 
tion to the extent of their local manifestness. The morbid poisons in 
high doses destroy before local manifestation or detriment commences. 
The poison of yellow fever, scarlatina, cholera, &c., may kill, and leave 
no sign. The patient may die in the first access ; in the first tremendous 
shock or depression the vital powers sustain. At Muscat, ten minutes 
sometimes only elapsed from the first seizure of cholera before life was 
extinct. At Punderpore, the disease is said to have raged with such 
severity, that 350 persons died in the streets, tumbling over each other 
lifeless ; or, according to an eye-witness, " as if knocked down dead by 
lightning." 

Another strong objection to this theory is, that its advocates have 
failed to show the presence of parasitic bodies in connection with the 
specific diseases. The cholera fungi were a miserable delusion. You 
do not find them in the pustules of smallpox ; in the virus of a chancre. 



INFECTION — KINDS OF. 87 

Not only, then, do not analogous symptoms to those ohserved in recognized 
parasitic diseases, in those affections where parasites are constantly found, 
occur in epidemic and contagious disorders, but no evidence has been ad- 
duced by the supporters of the theory to prove their presence. It is only 
conjectured ; they admit they have eluded discovery ; they are, they 
admit, not yet tangible to the senses. Before, then, admitting that their 
doctrine is worthy of serious discussion, is it too much to ask that their 
occasional presence be alleged ? — C] 



III. INFECTIOUS CAUSES. 

93. The terms infection and contagion are applied to the production 
of a disease by a morbid matter proceeding from the body of another per- 
son who is, or has been, the subject of the same disease. The proofs 
that disease is thus progagated from one individual to another, are, first, 
the general one, that those who have intercourse with the sick are af- 
fected in much greater numbers than those w^ho have not (§ 12) ; and, 
secondly, the direct and individual proof of infecting a healthy person 
with matter taken from a person in disease. This, although available 
only in some modes of infection, may be considered as a proof of the 
fact of contagion in general — that is, of disease propagating its kind. 

94. I have just alluded (§ 93) to differences in modes of infection ; 
they may be farther enumerated as follows : — 

(1). Infection through wounds, or an abraded surface ; as in hydro- 
phobia, the morbid matter being contained in the saliva or guttural 
mucus of the rabid animal ; and in cowpox, the matter being contained 
in the specific vesicle, and acting on a puncture or abraded surface. 

95 (2). Infection by contact, different parts of the body being sus- 
ceptible of different diseases ; as the urethra and conjunctiva in gonor- 
rhoea, the vicinity of the external openings of the passages in syphilis, 
the skin in scabies, the scalp in porrigo — the morbid matter generally 
proceeding from similar parts. 

96 (3). Infection by exhalation from the breath, perspiration, or other 
secretion, conveyed through the air to the mouth and air-passages ; as 
in the case of measles, scarlatina, hooping-cough, typhus, and other 
infectious fevers. 

97. Some diseases may be propagated in several of these modes ; 
smallpox, for instance, may be communicated by punctures in the skin 
(§ 94), by inoculation — application to the eye (§ 95) — and by diffusion 
through the air (96) ; and probably the same might be effected with 
other febrile poisons, if their precise source in the body were as clear 
as it is in smallpox. These different modes of infection merely show 
that the infecting matter can exist suspended in the air, as well as in a 
fluid or solid state ; and according to these conditions, it may get access 
to the system by different avenues. 

98. Many of those who are skeptical as to the reality of infection, 
aim their objections only against aerial infection, and do not question 
the other modes. But the difficult problem is, not that the infectious 
matter may be diffused through the air — our smell informs us that 



88 EXCITING CAUSES OF DISEASE. 

animal effluvia are constantly so diffused — but the difficulty lies in the 
fact of infection by any mode ; that is, that disease should propagate 
its kind. There are only two parallel cases in nature, in which analo- 
gous properties are possessed by matter. One is the case of what is 
called septic matter, leaven, or ferment ; a little of which introduced 
into organized matter will promote changes and decompositions : " A 
little leaven leaveneth the whole lump." This property is supposed by 
Liebig and other chemists, to be chemical, operating in the manner of 
heat, by altering the molecular relations of compound matter ; but by 
Turpin, Cagniard De la Tour, and others, it is stated that fermentation 
is caused by the production and growth of living molecules or vegetables, 
and that it spreads by the propagating power of these. This would 
transfer this case, that of leaven or ferment, into the next category 
(§ 99). 

99. The other case analogous to propagation of disease by infection, 
is the vital power of generation ; in this case, as in that of contagion, 
matter propagates its own kind in the animal and in the vegetable 
world. Does the matter of contagion consist of animal ova or vege- 
table seeds ? Are infectious diseases the results of the invasions and 
operations of living parasites, disturbing in sundry ways the functions 
and structures of the body, each after its own kind, until the vital 
powers either fail, or succeed in expelling the invading tribes from the 
system (§ 16)? Such an opinion has been many times proposed, and 
is, in a degree, implied in the term incubation (sitting on eggs to hatch 
them), commonly applied to the period between the reception of the 
infection and the first appearance of the symptoms. In support of this 
notion, may be adduced the case of itch, which certainly infects by an 
insect, the itch-mite, and spreads by this animal's propagation ; and the 
case of porrigo, or favus, which depends on a minute parasitic vegetable, 
and infects through its seeds or sporules.' But these, it may be objected, 
are instances of mere local disease, and by no means like the cases of 
infectious fevers and syphilis, which affect the whole system. 

The case of smallpox and cowpox might seem to be more intelligible, 
because the infectious matter is found to reside in the incipient pustule ; 
but this throws no farther light on the subject ; and although M. Gruby 
has reported that he has found a fcAv animalcules in the lymph of these 
vesicles, its disseminating property has not been traced to them. 

[The term now employed to designate the specific exciting causes of 
contagious and infectious diseases is morbid poisons. 

By morbid poisons, we understand a product which is the supposed 
specific cause of certain specific diseases, as syphilis, for example, gland- 
ers, scarlatina, smallpox, hydrophobia, and the like ; a poison which 
has striking differences from all other poisons, but chiefly these ; that 
whilst other poisons, as hydrocyanic or oxalic acid, act directly in pro- 
portion to their dose, becoming more or less deadly in proportion as 
more or less of them is brought to bear on the organism, you observe, 
on the contrary, that the morbid poison (the poison of contagion or 
infection) produces its characteristic results on the economy with as 

1 Schonlein, Miiller's Archiv. 1839, p. 82. Gruby, Gazette Medieale, Juillet 17, 1841. 



INFECTION — KINDS OF. 89 

much certainty, and quite as malignantly, when received in the minutest 
conceivable doses, as when the system is saturated with it. And secondly, 
while other poisons diminish from the body, or at the most, remain sta- 
tionary, morbid poisons undergo, within the body on which they act, a 
striking and singular increase. 

The phenomena which follow infection with a morbid poison, consist 
of certain local changes, attended by a peculiar constitutional state. 
The local changes may be generalized as subacute inflammatory pro- 
cesses; attended, perhaps preceded, by the deposition of sl specific mate- 
rial, which material in most cases contains an agent capable, by inocula- 
tion, of producing in another person the same symptoms as have 
attended its own generation in the original suiferer. The peculiar 
constitutional state is one essentially of depression ; modified, no doubt, 
and mixed with those phenomena of reaction which the living body, 
from its intrinsic conservative elasticity, so to speak, always opposes to 
the direct pressure of exterior influences. Of the local changes, partak- 
ing of an inflammatory character, the pustules of smallpox, the cynanche, 
erythema, and kidney affection of scarlatina ; the follicular intestinal 
eruption in continued fever ; the suppurating tumors of glanders ; the 
parotitis of mumps, may be cited as some amongst many illustrations. 
And it is because of these local differences in effect, that we are led to 
distinguish the causes, and to speak of them as effects. Syphilis never 
causes ulcers in the ileum, scarlatina never causes iritis. The causative 
poison of the one disease differs from the causative poison of the other, 
for on the self-same subject it produces different effects. Not so, or in 
a much inferior degree, w^ith the constitutional state which precedes 
and accompanies the local changes. With slight modifications, the 
general or constitutional symptoms are the same in all the acute in- 
fectious diseases. We are not able to distinguish with certainty the 
nature of the poison, until the local manifestations occur. The admix- 
ture of the symptoms derived from local changes is the first evidence of 
the precise character of the malady. Our knowledge of its speciality 
depends on its local manifestations.* — C] 

100. The parasitic nature of infectious matters may receive some 
support from the little that is known of their general properties, which 
farther deserve to be mentioned on account of their practical import- 
ance. Infectious matter is destroyed by a temperature above 120° 
Fahr., and by strong chemical agents, especially chlorine ; its activity 
is impaired by cold ; and in case of aerial infection, by intense cold and 
free ventilation, it is rendered harmless. Hence many infectious dis- 
eases cease when hard frost sets in. On the other hand, warmth, close- 
ness, and filth increase the virulence of contagion, and become, as it 
were, a nursery of pestilence. Nothing tends to promote the spread of 
an infectious disease more than crowding together several who are suf- 
fering under it. Each one is a separate source of contagion ; and if 
these sources are multiplied in an apartment, the air will be contami- 
nated in proportion. This is the chief reason why, in fever hospitals 
and fever wards, medical attendants and nurses escape infection much 

' See Simon's Lectures on Pathology, &c. 



90 EXCITING CAUSES OF DISEASE. 

more rarely than in hospitals where the fever patients are widely dis- 
tributed among other patients. 

101. It may be useful, again, to point out the peculiarities which 
distinguish infectious from endemic and epidemic diseases; for these 
peculiarities are proofs of the reality of infection as a separate cause 
of disease. 

Infectious diseases first attack individuals in any locality, then gradu- 
ally spread in the vicinity of those diseased, or in the direction where 
there is most human intercourse. Where care is taken early and com- 
pletely to separate the diseased from the healthy, disease does not 
appear among the latter. 

102. Endemic diseases may simultaneously attack many individuals 
in certain localities only (§ 81) ; they do not spread beyond these locali- 
ties ; no separation of the sick from the healthy w^ill save the latter, but 
removing the healthy to another spot gives them security. 

103. Epidemic diseases simultaneously attack numbers in any locality 
(§ 88) ; they increase not peculiarly in the vicinity of those first aifected, 
nor in proportion to intercourse with them, but rather in proportion to 
the prevalence of other conditions that may be called predisposing or 
determining causes (§ 19). 

104. It must not be forgotten that some diseases are suspected to 
originate and spread in two, or even all, of these modes. Perhaps this 
may be said of typhus fever, plague, cholera, and dysentery. It has 
been already mentioned that infectious diseases, as smallpox, scarlatina, 
and measles, are occasionally increased and modified by epidemic influ- 
ences (§§ 90, 91) ; and the same thing may be said of some endemic 
maladies. So also the aggravation of contagious and epidemic complaints 
by endemic impurities (§ 85), makes it plain that all the class of causes 
may operate conjointly. It is under such circumstances of aggravation, 
or under those of strongly prevailing predispositions, as from famine 
(§ 21), fatigue (§ 23), confinement (§ 22), or mental depression (§ 28), 
that this class of diseases becomes so destructive as to be called pesti- 
lential, or malignant. 

105. The direct operation of most of this class of causes is depressing, 
and, where they are strongest and prevail most, the resulting disease 
is one of depression, adynamia^ asthenia, or prostration of the vital 
powers. These causes, as exhibiting a noxious property opposed to life, 
are therefore commonly designated specific poisons. But there is the 
antagonist principle of vital resistance in the system (§ 16), which leads 
to various processes of reaction, which may be exhibited in different 
degrees, according to the relative strengths of the poison and of this 
resisting power ; and likewise often according to various cognizable 
agents which simultaneously act as predisposing, determining, or co- 
operating causes. For instance, in warm weather the poisonous influ- 
ences are generally strong (§§ 84, 100), and the bodily powers weak 
(§ 24) ; the resulting disease is one of more complete adynamia. In 
moderately cold weather, on the other hand, the specific poison is less 
active, and the system is ready to react, not only against it, but against 
the cold with which it may be combined ; this causes a more inflamma- 
tory type in the consequent disease (§§ 79, 81). 



91 



CHAPTER II. 

PATHOLOGY (PROPER)— THE NATURE AND CONSTITUTION OF DISEASE. 

106. Disease is a change from the natural condition of the function 
or structure of the body (§ 6, et seq.) ; but the change is generally more 
or less compound, involving several elementary functions or structures ; 
and it is obvious that we cannot obtain an accurate knowledge of the 
nature of disease until we have ascertained that of its component parts. 
As the anatomist and the physiologist examine structures and functions 
by separating or analyzing them into their constituent parts, before he 
contemplates them in combination, so should the pathologist study these 
constituent parts, or elements, in disease, before he can understand their 
combinations.^ 

The chemist, in the examination of his subjects, finds that there are 
some principles or elements that cannot be analyzed or divided further ; 
these he calls ultimate or primary elements ; others, again, are simple 
compounds, which may be analyzed ; but they occur so constantly, and 
act so singly in compounding and giving properties to complex matter, 
that they are called proximate principles or secondary elements. A 
parallel case might be shown of physical science. 

107. So it should be with physiology and pathology.^ There are the 
healthy and diseased primary or ultimate elements of structure — mus- 
cular fibre, nervous matter, vascular fibre, and the elementary tissues of 
membranes, glands, skin, and other parts ; and there are primary ele- 
ments, healthy and diseased, of function of these same structures — 
irritability, tonicity, nervous properties, to which may be added, because 
at present we cannot analyze it, the power of secretion and nutrition ; 
and lastly, the constituents of the blood, xind there are the secondary 
or proximate elements of disease, composed of the preceding primary 
elements, but still simple in comparison with the complex conditions of 
disease which they combine to produce. 

' A neglect of this precept has greatly retarded the adTancement, nay, even the forma- 
tion, of pathological science. ^len have begun with the very complex problems of inflam- 
mation and fever, before they have made themselves acquainted with the elementary 
properties of textures or even of vessels. The result has been that the most profound 
reasoning and ingenious speculations have been wasted on nonentities, such as spasm of 
the extreme vessels, increased action of the capillaries, &c. ; and even observation has 
been confused by the complexity of the subjects brought under it. 

2 I have pursued this synthetic mode of teaching general pathology in my lectures, from 
the year 1839 to the present time. I am not aware that it has been fully used by any 
other writer, although several (as Andral and Carswell) have partially recognized it in 
their divisions of the objects of morbid anatomy; and my friend. Dr. Symonds, has ad- 
verted to the parallel of chemistry, and actually employed the term proximate principles 
of disease in the same sense in which I use it. — Tweedie's Library of Practical Jledicijie, 
vol. i., Pathological Introduction. 



92 



ULTIMATE ELEMENTS OF DISEASE. 



108. The varieties of disease affecting these several elements may be 
comprehended under the heads of degree and kind; degree, including 
excess and defect, or alterations of plus and minus ; and kind, relating 
to changes not comprised under these heads, but otherwise expressed 
by the term p)erversion. By applying these heads to the elements of 
structure and function, we obtain a simple and comprehensive classifi- 
cation, which embraces all the important topics of general pathology. 

109. The following table presents this classification applied to the 
primary or ultimate elements. 



PRIMARY ELEMENTS OF DISEASE. 



PRIMAEY CONSTITUENT. 

Contractile fibre .... 

Nervous structure . . . 

Secreting structure . . . 

Constituents of tlie Blood: — 
R,ed particles, 
Fibrine and white globules, 
Albumen, 
Oil, 
Salts, 
Water. 



FUXCTIOX. 

r Irritability, 
\ Tonicity, 
r Sensibility, 
J Vol. motion, 
I Reflex action, 
1^ Sympathy. 
. Secretion. 



DISEASE. 



STRUCTrHAL DISEASE. 



' Excess, Hypertrophy. 

Defect, Atrophy. 

Perversion, Degeneration, &c. 



Changes of the Blood: — 
By Respiration, 

— Secretion, 

— Assimilation, 

— Foreign matters. 

110. In the choice of proximate or secondary elements of disease, we 
must be more arbitrary and less comprehensive ; otherwise we shall en- 
croach on the domain of special pathology. The vascular system and 
the nutrient function, so intimately connected with it, present us with 
the best and most important examples of proximate elements, compris- 
ing, as they do, two or more of the preceding ultimate elements (irrita- 
bility, tonicity, constituents of the blood, secretion, &c.), yet so universal 
throughout the body as to belong to the province of general pathology. 

PROXIMATE ELEMENTS OF DISEASE. 
r General 
Defective — Anjemia ^ 

( Partial 



'General — Plethora - 



The blood in 
circulation 



ID Increased — Sthenic. 

9 



Diminished — Asthenic. 



lO 



Excessive — Hypersemia 



^Perverted — Cachaemia 



Increased — Determination. 



,„ ^. , -r , , -rs Diminished — Congestion. 

'Partial — Local hv- ti ° 



pei'Eemia 



^-1 



2 Partly inc. | j^g 
Partly dim 



^- - -■ J j tion. 



IRRITABILITY. 93 



Nutrition of / 
Textures \ 



Defective — Atrophy. 
Excessive — Hypertrophy. 

' Degenerations. 



Perverted- 



Deposits. 
^ Growths. 



These primary and secondary elements of disease are the especial 
subjects of general pathology. By the study of them we become ac- 
quainted with the materials of disease, and their relations to each other; 
we learn how special diseases arise, and of what they consist; how they 
produce their phenomena and effects; how they are to be known, dis- 
tinguished, and classified. Out of such a knowledge, where it is correct, 
sufficient, and combined with an ample acquaintance with the properties 
of remedial agents, arises the rational method of relieving, curing, and 
preventing disease, the great ends of the art of medicine. 

I readily admit that our knowledge of these elements or principles in 
pathology, is as yet too limited to be entitled to rank as a complete sci- 
ence ; but I think that the attempt to describe and illustrate them will 
be useful, not only by making available all that is known on the subject, 
but also by showing what is • not known, and needs investigation ; thus 
suggesting fit subjects for farther research. 



FUNCTIONAL OK DYNAMIC DISEASES. 
PRIMARY ELEMENTS. 



SECTION I. 
PROPERTIES OF THE MOVING FIBRE .—IRRITABILITY. 

111. Irritability, irritable contractility, or the property of contract- 
ing on the application of a stimulus or exciting agent, is the distinctive 
property of muscular fibre. Although some physiologists maintain that 
this property is derived from some part of the nervous system, they have 
not produced any conclusive proof to that effect ; it is, therefore, more 
philosophical to retain the Hallerian view of intrinsic irritability.^ 

^ Dr. M. Hall ascribes irritability to the spinal marrow; but he mentions an experiment 
which is conclusive against this yiew: " During the half lethargic condition of the frog 
in winter, the entire cerebrum and spinal marrow may be removed, by slow degrees, at 
considerable intervals ; the circulation is nevertheless good." — Gulstonian Lectures^ 1842, 
p. 60. The irritability of the heart, therefore, is unimpaired. The late experiments of 
Dr. John Reid, on muscular irritability, are strongly in support of the Hallerian doctrine. 



94 ULTIMATEELEMENTS OF DISEASE. 

It may become excessive, so that the contraction is too violent for the 
welfare of the part or of the system. This constitutes spasm or con- 
vulsion. The excess of irritability may be manifest in three ways: 
1. By an excessive strength and degree ; 2. By an inordinate quick- 
ness, or promptitude ; 3. By the unusual duration of the contractions. 

112. (1). Excessive strength of muscular contraction is exemplified 
in the violent action of the heart during exertion or other excitement ; 
and in the extraordinary muscular power of a delirious patient, who 
can master persons naturally stronger than himself. This exaltation 
of the natural property may depend on the excessive stimulus, as of 
blood in the heart, or of nervous excitement in the case of the delirious 
patient ; or it may arise from the muscles being over-fed with blood. 

113 (2). Inordinate readiness or quickness of contraction constitutes 
mobility of muscle, a slight stimulus causing it to contract. This often 
coexists with want of power or completeness in the contractions. It 
is exemplified in the irritable heart, which, although acting very fre- 
quently, does not expel its contents so vigorously as in health. It is 
seen in the quick nervous movements of irritable persons, who are at 
the same time weak. The bowels show it in that irritable looseness 
formerly called lientery, in which food is quickly passed little altered ; 
and it is instanced in the irritable bladder, which will not hold even an 
ounce of urine. The pathological cause of this kind of inordinate 
irritability is either an undue flow of blood to the muscle, which exalts 
its natural property, or a predominance of irregular nervous influence, 
which unduly excites this property ; thus it is often excited by irrita- 
tions of the motor nerves, or of their columns or fibres. But the most 
remarkable examples are given in the extreme case of convulsions or 
clonic spasms — that is, sudden contraction, alternating with relaxation, 
as seen in chorea, epilepsy, and convulsive hysteria, where it affects the 
voluntary muscles ; and in the palpitating heart, which beats irregularly 
and out of rhythm. 

114 (3). An unusual duration of muscular conti'action constitutes 
tonic spasm, or cramp, in which the contraction is strong, and not alter- 
nated, as usual, with relaxation. Such spasms are not unfrequently 
felt in the calves of the legs ; and in the different muscular canals, the 
gullet, the stomach, the intestines, and the glottis, which occasionally 
present this state of continued contraction. In most of these cases, 
it is accompanied by pain more or less severe, and may lead to seriou? 
obstruction to the function of the organ. When in a more moderate 
degree affecting the voluntary muscles generally, it constitutes catalepsy, 
in which, from the muscles remaining contracted, the limbs will retain 
whatsoever attitude they are placed in, until the spasm is over. But 
the extreme example is tetanus, in which the spasms are so violent and 
so enduring, that they may be said to squeeze the patient to death. 
The pathological cause may be, as in other modifications of irritability, 
either an irregular supply of blood to the muscle, or irritation, direct 
or indirect, of the motor nerves by which the muscles are excited. 

115. liemedial Measures. — These must depend on the cause of the 
excessive irritability. Where there is increased flow of blood to the 
part, bloodletting, derivants, sedatives, and other remedies for determi- 



REMEDIAL MEASURES. 95 

nation of blood, may be proper. Firm pressure on muscles aifected 
with, spasm or cramp, will promote their relaxation. I have succeeded 
in opening the jaw in trismus, by using strong steady pressure on the 
masseter muscles. Where the cause is nervous irritation, narcotics are 
the most effectual ; and some of these, from their peculiar efficacy in 
allaying spasm, are called antispasmodics. The most powerful of these 
are stramonium, belladonna, sulphuric ether, in draught or inhaled, 
opium, and Indian hemp. "Where irritability is combined with Aveak- 
ness, tonics are often serviceable, especially the metallic tonics and 
bark. In such cases the muscles are usually weak and ill-nourished, 
and their excitability is dependent on exalted function of the excito- 
motory nerves ; the remedies will therefore be noticed under the head 
of nervous diseases. 

116. Muscular contractility may be defective chiefly in two modes. 
1. In force (§ 112); as in the weakness of voluntary muscles during 
severe illness, after fatigue (§ 68) ; or under the influence of a depress- 
ing poison or shock (§ 55) ; and in the weakness of the heart under 
similar circumstances, and in faintness, or in the sinking which precedes 
death. This weakness is caused by the exhaustion of previous exer- 
tion, or by want of a due supply of blood, which is necessary to main- 
tain all functions ; or it may proceed from an influence positively 
depressing or destroying the muscular power, as in the case of sedative 
poisons, as tobacco, sulphuretted hydrogen, &c., and probably concus- 
sion and other violent injuries to the organization. The extreme effect 
of these agents is to cause paralysis, or complete loss of irritability, 
which, affecting the heart, constitutes death by syncope. Muscles 
sometimes lose their irritability by more gradual causes, such as rheu- 
matic inflammation, the action of lead, &c. Muscles are reduced in 
power either- by over-excitement or exertion on the one hand, or by 
disuse on the other ; this is exemplified in the paralysis of the sphinc- 
ter after over-distension of the bladder, torpor of the bowels after the 
operation of an active purgative, &c., and in the weakness and ultimate 
palsy of the muscles of an anchylosed limb. 

117 (2). Muscular irritability may be deficient in readiness to con- 
tract (§ 113), as in the sluggish movements of a person whose irrita- 
bility has been lowered by opium ; and in the slow pulse caused by 
digitalis, and by some cerebral affections ; and in some cases by blood- 
letting or low diet. It is by no means clear why the same agents 
should lower in some cases the strength, and in others the promptitude 
in contraction ; and in many other respects, the laws of irritability 
require further investigation. A benumbing degree of cold greatly 
reduces the irritability of muscles ; yet the sudden dash of cold water 
will sometimes restore power reduced by exhaustion or sedatives. 

118. Although it has never been proved that muscular irritability is 
derived from the nervous system, yet the illustrations already given 
plainly point out that it is much under its influence. The nerves are 
the proper medium by which the voluntary muscles are made to act, 
and through the nerves the motions of the involuntary muscles are 
influenced, as instanced in the operation of mental emotion on the 
action of the heart (§ 69). Hence diseases of muscular action gene- 



96 ULTIMATE ELEMENTS OF DISEASE. 

rally rank with nervous diseases. Thus disease of the brain may cause 
a cessation of muscular motion by suspending volition ; and disease of 
the spinal marrow or nerves may do so by intercepting the influence of 
the will ; in either case, motion of a muscle ceases, not from disease in 
itself, but for w^ant of its proper stimulus. In fact, under these cir- 
cumstances, muscular irritability sometimes accumulates (§ 111), and is 
brought into action by slight impressions reflected from the spinal 
marrow. Thus, in complete paraplegia, or loss of motion of the lower 
half of the body, convulsive movements may be excited in the lower 
extremities by tickling the soles of the feet ; in other cases of paralysis, 
they may be produced by electricity. 

119. Remedial Measures. — As usual, these will vary with the cause 
of the defective irritability ; where it proceeds from exhaustion, repose 
is the obvious indication. But even here, in extreme cases, and more 
particularly in those of the second head (§ 117), it may be necessary at 
once to excite the defective irritability by stimulants, especially those of 
the more difi'usible kind, as ammonia, brandy, and other spirits and 
essential oils ; whilst the feeble circulation and restoration of muscular 
power may be aided by heat and frictions. The large quantity of 
stimulants borne by patients whose irritability is reduced by accident 
or disease, is a remarkable feature in their history. A person faint 
from great loss of blood (§ 71), a crushed limb (§ ^b), or a sedative 
poison, will bear four or five times more brandy than would be sufiicient 
to intoxicate him under other circumstances. Electricity and the dash 
of cold water should be mentioned among temporary means of exciting 
defective irritability. Strychnia and cantharides given internally, are 
reputed to restore power to paralyzed muscles ; but the same agents act 
much more energetically when directly applied to the affected part by 
means of blisters. So likewise stimulant frictions, warm douches, and 
such means of promoting a vigorous circulation throughout the weakened 
muscles may assist in restoring their strength ; and generous diet, with 
tonics and a healthy air, render the blood richer in fibrine, by which the 
muscles are nourished. 



SECTION 11. 

TONICITY. 

120. Tonicity, or tone, is a property possessed by all muscular struc- 
tures, and by some which are hardly accounted muscular. It is a tend- 
ency to slow, moderate contraction, not essentially terminating in re- 
laxation ; but it keeps the parts in which it resides in a certain degree 
of tension. This tone keeps muscles and limbs in their places when at 
rest, and out of their places when dislocated ; if one set of muscles is 
paralyzed, the tone of their antagonists draws the parts in an opposite 
direction, as we see in paralysis of the portio dura on one side of the 
face. A similar property is possessed by the intestinal tube, the urinary 
bladder, the air-tubes, and the middle coat of the arteries, and gives 



TONICITY. 97 

them a constant tendency to contract on their contents. In these, but 
particularly in the arteries, it performs an important part, both in health 
and in disease. By this the arteries contract, when they cease to 
receive blood from the heart, and thus are found empty after death. It 
adapts them to different degrees of fulness, yet maintains in their walls 
a certain tension favorable to equality in the motion of the blood. 

It has been asserted that tonicity is quite distinct from irritability, 
and although irritable fibres possess tone, tonic textures are not irritable. 
This is not true with regard to the arteries ; for I have many times dis- 
tinctly seen them slowly contract, and remain contracted, at a point to 
which an irritant, mechanical, chemical, or electric, has been applied. 
The late discovery, by Henle, of a structure distinctly muscular in 
arteries, confirms this observation. I have proved, in like manner, the 
irritability of the air-tubes, which move more rapidly under a stimulus 
than the arteries ; whilst that of the intestines is still higher in degree, 
but still inferior to that of the oesophagus and voluntary muscles, the 
contractions of w^hich, on the application of a stimulus, are abrupt, and 
immediately followed by relaxation. So far, then, it appears, that 
tonicit}^ is influenced by the same agents which excite irritability ; but 
another agent, temperature, seems to aifect them differently (§§ 74, 75). 
Cold increases tonicity and impairs irritability. Under the influence of 
cold, vessels generally, but especially arteries, shrink in size very 
remarkably;^ and the muscles and other textures present a firmness 
and contraction w^hiph impede the quickness of motion characterizing 
the highest degrees of irritability. Under the influence of heat, on the 
other hand, although muscles are relaxed, they are more irritable, and 
the pulsations of the heart are more frequent. 

Cold and heat, therefore, become the best tests for tonicity ; and by 
their means we find this property to be possessed by textures which are 
not distinctly muscular ; I mean, the veins and the cutis, which, in a 
remarkable degree, contract with cold, and becom.e relaxed with heat.' 

Now this property, tonicity, is a very important one in the animal 
economy, its natural condition being very necessary for the preservation 
of health, and its modifications being concerned in causing and consti- 
tuting disease, more particularly in the vascular system. Practical men 
have long admitted the existence of something of this kind, without 
defining or localizing it ; and the terms tone and atony, bracing and 
relaxation, tonic and relaxing remedies, become quite appropriate in 

^ This fact must be familiar to every one who has noticed the difference of the pulse 
"when a limb is cold and when it is warm. But I have seen it more forcibly illustrated by 
experiment. On plunging into cold water the aorta of an ass just dead, it contracted so 
closely as to obliterate its cavity ; and it required some force to pass the little finger into 
it. The crimping of the flesh of fish is referable to the same principle. 

2 It is difficult to assign the limit between textures that are irritable and not irritable. 
Thus some large venous trunks, as the cava, have been found by Valentin to exhibit 
slight contractions on the sympathetic nerve being irritated ; and fibres like those of an 
unstriated muscle, have been found in their coats. The irritability of the dartos is well 
known; but I have frequently seen the skin of the trunk and limbs contract, and cause 
the projection of the papillae (presenting the appearance of the cutis anserina), on gently 
scratching or tickling the surface, the appearance being confined to the vicinity of the 
part tickled. 

7 



98 ULTIMATE ELEMENTS OF DISEASE. 

connection with this property. Let us notice some of the characters of 
its excess and defect, 

121. AYhere there is an excess of tonicity, the muscles are so firm that 
there is scarcely room for supple motion ; the pulse is hard, tense, and 
often slow, yet there is scarcely any interval hetween the heart's beat 
and the radial pulse. The capillary circulation is active, and the ex- 
tremities warm ; but owing to the tense state of the vessels and of the 
skin, the secreting organs do not act freely, the urine is high colored, 
the bowels are disposed to be costive, and the skin to be dry and hot. 
The vascular system is in a state of high pressure, under which any 
weak part may give way, and induce local congestion or flux, active 
hemorrhage or inflammation, apoplexy and gout ; but there is less than 
usual proclivity to suff'er from cold, endemic and infectious influences, and 
others of a depressing character. The causes of excessive tonicity may 
be an over-nourishing and stimulating diet ; with want of sufficient 
exercise ; a dry bracing air ; tonic medicines, such as iron and bark ; 
the excitement of fever, &c. 

122. Remedial Measures. — In such a state bloodletting will reduce 
the tension of the vessels, but only for a time. As long as the tonic 
fibres are too much braced, and the pulse hard, the secretions will be 
defective, and the vessels will fill again and renew the evil. The mea- 
sures best suited for this state of excessive tone, are those tending to 
relax the tonic fibre, and increase the secretions ;, such as warm bath- 
ing, exercise, sudorifics, aperients, and diuretics, with moderate diet. It 
is probable that some remedies such as antimony, reduce directly the 
tone of the vascular fibre, acting as relaxants. We shall have to advert 
to this subject again under the head of inflammatory fever, of which the 
element, excessive tone of the vascular system, is a chief constituent. 

123. Where tonicity is defective, the muscles are flabby, and incapa- 
ble of continued exertion, but sometimes are too irritable, with the 
tremulousness of debility (§ 113). The heart, likewise, is irritable, and 
often exhausts its strength in palpitation ; the pulse is soft and yielding ; 
it may be full when slow, and sharp when frequent ; but it is without 
firmness or endurance, and is easily accelerated. Another distinctive 
character is its retardation, increasing the interval between the heart's 
beat and distant pulses; so that the radial pulse is often' felt after the 
second sound of the heart is heard (§ 121) ; the tubes being less tense, 
the pulse-wave is slower than usual (§ 120). Sometimes the absence of 
that tightening of the walls of the arteries, by which the tonic fibres 
control their movements, permits their mechanical elasticity to come into 
play, and this reacting after each stroke of the heart gives that peculiar 
reduplication or rebounding of the pulse, which has long been described 
under the term dichrotous pulse. This is often observed in convales- 
cence from fevers and other diseases, after the subsidence of vascular 
excitement. A loose, relaxed state of the vessels renders the circulation 
in distant parts weak, so that the extremities are cold, whilst the head 
and internal organs may be congested. Sudden exertion or change of 
posture may disturb the circulation and cause faintness or giddiness. 



SENSIBILITY. 99 

Want of tone also in the stomacli and intestines causes indigestion and 
costiveness, and permits them to become distended with wind and accu- 
mulating feces. The secreting organs, irregularly supplied with blood, 
are also liable to disorder, being either scanty, depraved, or profuse and 
watery. 

It is quite obvious that a person in such a condition must be prone to 
various diseases. He has no resisting power (§ 16) against malaria, 
infection, or other depressing agents. If he is exposed to cold, the blood 
is readily driven through the weak vessels into the interior (§ 79), where 
it causes congestion or inflammation. The weak intestines have no 
power to expel oifending matter from them (§ 57). Thus the system in 
a state of atony is open to the action of many exciting causes of disease; 
besides being itself in many respects on the verge of disease, especially 
congestion and its consequences, and other derangements of the circu- 
lation. 

The causes of loss of tone are various debilitating influences (§ 28, et 
seq.\ such as continued and exhausting excitement of the vascular sys- 
tem (§ 64), continued heat, especially with moisture, confinement in 
impure air, defective nutrition (§ 63), imperfect excretion (§ 68), &c. 
Muscles lose their tone from want of exercise, and bloodvessels from 
the continued operation of cold (§ 77). The tonicity of the arteries is 
liable to be influenced remarkably by the nervous system ; and we shall 
hereafter find that a relaxation of the arteries of a part is the chief 
cause of local determinations of blood. 

124. Remedial Measures. — The proper remedies for defective tonicity 
are tonics, which are agents that tend to increase the tone of the whole 
system (§ 120), particularly of its muscular and vascular parts. We 
have already stated that cold has this eff'ect in a marked degree (§ 30), 
and in truth, cold properly applied, is one of the best tonics which we 
possess. For this purpose its application should be sudden, and too brief 
to cause depression or any of its morbid eff'ects. The shower-bath and 
plunge-bath are the most efi'ectual forms ; and free sponging, with cold 
salt water, is applicable even to weak subjects. A pure bracing air and 
much exposure to it, with moderate exercise, have also useful tonic 
efi'ects. There are many medicinal tonics, the most efi'ectual of which 
are bark and its preparations, medicines containing iron and the mineral 
acids. Generous living may be considered a part of a tonic plan, in 
so far as it tends to enrich the blood, which sustains tonicity, as well as 
all other vital properties. 



SECTION III. 

FUNCTIONS OF THE NERVES. — SENSIBILITY. 

125. Certain parts of the nervous system being known to the instru- 
ments of sensation, we have no difficulty in tracing diseased sensibility 
to this system ; and as this system consists of a medullary centre, and 
of nerves converging from various parts to it, so we find that altera- 



100 ULTIMATE ELEMENTS OF DISEASE. 

tions in the property may depend either on disease of the centre, caus- 
ing disorder of general sensihility^ or on disease of one or more of 
the nerves, causing disorder of local sensihility . These we shall now 
notice. 

DISEASES OF GENERAL SENSIBILITY. 

These may consist in — 1, excess ; 2, defect ; 3, perversion. 
126 (1). Excessive sensihility is more or less present when the nerv- 
ous centres are excited in the early stage of their inflammation or of 
determination of blopd to the head; where there is intolerance of light, 
noise, and motion. A similar condition exists in hydrophobia and teta- 
nus from mere excitement, without inflammation. But short of these, 
sensibility is excessive in some persons, either congenitally (§ 41), or 
as a consequence of disease (§§ 31, 34). Such persons are commonly 
called nervous; they are worried with trifles; startled at shadows; dis- 
tracted by noise or bustle; never free from some ache or pain; for almost 
every feeling is suffering; and what in others would be slight pain, in 
these amounts to agony. Hence they are perpetual invalids, quite unfit 
for the rugged path of life, over which they, as it were, walk barefooted 
and thin-skinned. If real disease attack them, its nervous symptoms 
are so much exaggerated, that a medical attendant is apt to fall into 
the error of either ascribing all to "the nerves," or of measuring the 
disease by the severity of the symptoms. This over-sensibility is gene- 
rally conjoined with excess of irritability, and want of tone (§§ 113, 
123). Other nervous functions, such as s^^mpathy and reflex action, 
are also often augmented or in disorder. The symptoms connected 
with sensation most frequently present, are neuralgic pains of various 
parts, excessive sensibility of the surface, headache, pain in t]^e back or 
left side, and spinal tenderness. 

127. The pathological cause of increased general sensibility is proba- 
bly a slighter degree of the same cause which induces it in the early 
stage of encephalitis, an undue supply of blood to the posterior columns 
of the spinal marrow, the corpora restiformia, and the parts of the cere- 
bral mass concerned in sensation. This local determination of blood 
may result from original development; but it may also be a consequence 
of inflammatory affections of the encephalon, of irregularities in the 
menstrual functions, or of the reaction ensuing after great losses of 
blood, all of which are known to be sometimes the precursors of mor- 
bid sensibility. On a future occasion, in connection with the subject of 
irregular distribution of blood, we shall endeavor to point out why great 
losses of blood and other causes of sudden weakness are sometimes fol- 
lowed by excessive sensibility. The extreme refinements and luxurious 
habits of the upper classes, with more excitement for the mind than 
exercise for the body, and for the feelings than for the understanding, 
are well calculated to foster this over-sensitive state. 

128. Remedial Measures. — The medicines most directly in opposition 
to this element of disease are narcotics or anodynes, such as opium, hen- 
bane, hemlock, Indian hemp, &c., administered internally, or, in some 
instances, applied externally ; as where muriate of morphia is sprinkled 



EXCESSIVE SENSIBILITY. 101 

on the skin deprived of its cuticle by a blister. These diminish nervous 
sensibility; and in proportion as this is exalted (§ 126), the system will 
bear larger doses. But where the increased sensibility depends on in- 
flammation or vascular excitement of the nervous centres (§ 127), the 
proper treatment will obviously be that to be hereafter described as anti- 
phlogistic. Again ; where the excessive sensibility arises from the nerv- 
ous excitement of irregular circulation, from general weakness (§ 116), 
and loss of tone (by no means an uncommon combination), tonics (es- 
pecially the metallic) (§ 124) and stimulants (§ 119), as well as narcotics, 
are the proper remedies. Weakness, softness, and slow transmission of the 
arterial pulse (§ 123), and absence of fever or permanent heat of skin, 
are the chief symptoms of such a condition. In these and other com- 
mon cases of morbid sensibility, country air and exercise, cold or tepid 
bathing, especially with the shower-bath, plain food for both mind and 
body, early hours, and an avoidance of all enervating habits, are often 
more conducive to the cure than any medicines. 

An anodyne influence, more powerful in degree than that induced by 
any other agent, although transient in duration, is that resulting from 
the inhalation of the vapor of sulphuric ether, which has, during the 
last year, been extensively used, first in America, and subsequently 
in this country. The operation of this agent, and of nitrous oxide gas 
(which has a similar efl'ect), is on the sensorium, rather than merely on 
the sensitive nerves. In most instances, if continued for a sufiicient 
time, it induces complete insensibility, so that the subject may undergo 
the most severe surgical operation, and a female may go through the 
process of parturition, without suff"ering any pain. In many cases, how- 
ever, especially where the inhalation has been less prolonged, or less 
impregnated with ether, sensibility is blunted, but not destroyed, and 
the patient makes movements, and may utter expressions, indicative of 
slight pain, yet has no recollection of it w4ien restored to consciousness. 
The memory seems to be more afi'ected than the perceptive function. 
The power of voluntary motion is suspended in about the same ratio as 
sensibility ; but the reflex motions of the eyelids, breathing, &c., are 
lowered, but not abolished, unless the inhalation be continued so long 
as to induce complete asphyxia. 

The operation of ether vapor is obviously narcotic, like that of opium 
and alcohol ; and is more speedy and transient, because it passes freely 
and directly through the lungs into the arterial blood, and afi'ects the 
brain, and is as promptly dispersed by its diff"usion throughout the body. 
It has been maintained by many that it operates by its interference 
with the respiration, inducing a degree of asphyxia ; but so far is this 
from being the case, that its best effects are produced when the respira- 
tion is steadily maintained ; and it has always appeared to me that the 
end to be aimed at in the administration of ether vapor, is to narcotize, 
as far as possible, without too much embarrassing the breathing. This 
is difficult to accomplish without a freer supply of oxygen than atmo- 
spheric air contains ; and I should expect safer and more satisfactory 
results from the inhalation of a mixture of ether vapor with oxygen gas, 
which might be continued with safety for a much longer period than 
with the vapor and air only. 



102 ULTIMATE ELEMENTS OF DISEASE. 

Althougli the chief influence of etherization is transient, yet by sav- 
ing the nervous system from the shock of intense temporary pain, dur- 
ing an operation or paroxysm of suffering, it often prevents that con- 
sequent nervous irritation and exhaustion which are so injurious to the 
vital powers, and which favors the return of the painful attack. Thus 
in neuralgic and painful spasmodic affections, the removal of one or 
more paroxysms by etherization may break the habit of diseased action, 
and effect a permanent cure. 

129 (2). Defective general sensibility, in its extreme degree, is exem- 
plified in coma, from the circulation in the sensitive centre of the nerv- 
ous system being impeded by pressure, congestion, or other obstruction 
(§ 52), or from narcotic influence. Thus a person in a fit of apoplexy, 
or poisoned by opium, has lost all feeling, as well as voluntary motion. 
When the blood becomes impure by retention of excrementitious mat- 
ter, as in suppression of urine, a like stupor occurs (§ 68). Very 
rarely anaesthesia exists — that is, loss of sensation, without loss of motion. 
But short of these degrees, there are some who congenitally (§ 44), from 
disease (§§ 31, 34), or from age (§ 48), are deficient in sensibility — feel 
less than other folks. All their feelings are obtuse, and their actions 
slow ; they have no intense suffering or pleasure. Such persons have 
also little irritability, but much tone of fibre, and are remarkable for their 
immunity from many diseases. But they are the more liable to others; 
such as fulness of blood, apoplexy, gout, costiveness, and the various 
evils which these may bring. They contrast well with the over-sensitive 
in this, that disease, when it occurs, may be latent, advance far, and 
become dangerous, before it is felt ; and may imperceptibly increase until 
it is incurable, or until sudden death ensues. 

130. Remedial Measures. — When obtuseness of feeling arises from 
fulness, obstruction, or pressure of blood in the nervous centres, the 
treatment will consist in attempts to remove these by depletion, deriva- 
tion, and other means to be mentioned under the head of disordered cir- 
culation. Where there is no actual disease present, but merely a torpor 
of the sensitive function, mental excitement, bodily exertion, the cold 
dash and friction, are the best means of arousing the nervous system 
from its state of lethargy. The insensibility from narcotics and from 
retained excrementitious matters should be counteracted by means calcu- 
lated to eliminate the stupefying matter by the natural outlets, such as 
purgatives, diuretics, emetics, &c. It is doubtful wdiether we have any 
medicine capable of directly increasing sensibility. Strong tea and 
coffee, perhaps, have the best claim to such a property. What effect 
would arise from electrifying the spine and occiput ? Stupor and im- 
paired sensibility may arise in a state of anaemia, as in cerebral syncope, 
and in children or females who have lost much blood ; this is from stag- 
nation of the blood in the brain. Under such circumstances, the pallor 
of the skin and weakness of pulse would indicate stimulants as the best 
means of restoring sensibility. 

131 (3). Perverted general sensibility is often manifested by those in 
whom there is also increased sensibility (§ 126), but its character is in 



DISEASED SENSIBILITY — LOCAL. 103 

the peculiarity of the sensations which are experienced. Thus sensa- 
tions of tingling, prickly heat, trickling cold, in various parts ; feelings 
of a lump in the throat, a hot ball in the side, a fluttering at the stomach, 
and illusions of the special senses, may severally and variously affect 
persons whose sensibility is modified more in kind than in degree. Such 
persons may also have a depraved appetite, craving for sour things, 
cinders, mortar, and all manner of filth. These symptoms generally 
occur in females, often in connection with irregular menstruation ; there- 
fore, they are called hysterical ; but their pathological cause must be 
sought in the nervous system, the functions of which, probably from irre- 
gular supply or bad quality of the blood which supports them, become 
disordered. The remedial measures indicated for this condition are, 
therefore, those calculated to remove its cause ; chalybeates and other 
tonics, with pure air, nourishing food, and other means which improve 
the quality, and equalize the distribution of the blood. Narcotics and 
sedatives may be useful as temporary palliatives. In rare cases, the 
general sensibility is perverted by structural change in the nervous cen- 
tres, such as softening of the cerebral structure. 



DISEASES OF SENSIBILITY OF PARTS. 

132. The feelings of a part may be excessive, defective, or perverted. 
This may be illustrated by experiment. By irritating or striking a nerve, 
pain is produced in the part to w^hich it is distributed, and the sensibility 
of the part remains exalted ; that is, it feels tender or painful afterwards. 
By pressing on the nerve, a new and perverted sensation, of tingling 
and pricking, with numbness, is caused. By pressing more strongly, or 
dividing the nerve, the feeling is farther impaired or altogether destroyed. 
Similar effects may be produced by a tumor, ligature, effusion, or other 
cause pressing on a nerve in its course. Disease of the nerve, or of a 
part of the spinal or cerebral matter connected with it, may likewise 
modify the sensation of parts. Thus inflammation of the sheath of the 
ischiatic or trifacial nerves may cause first neuralgic pain, and after- 
wards numbness in the parts to which the nerve is supplied. There are 
other painful affections which are to be considered and treated as cases 
of exalted sensibility, such as the irritable (as Dr. Billing observes, erro- 
neously so called) breast, testicle, uterus, &c. 

133. But the function of sensation, as other functions, depends on the 
supply of blood to the extreme distribution, as well as to the trunk and 
origin, of the nerves. Hence, if blood does not circulate freely through 
a limb, the sensations are impaired ; and if it passes too freely, the sen- 
sibility is exalted, and there may be itching, tenderness, or even pain. 
In organs of special sensation, the senses are modified, together with 
the common feeling ; thus, in disease of the optic nerve or retina, there 
will be intolerance of light, or specks and clouded vision, or even blind- 
ness ; in the ear, ringing and beating noises, or deafness, besides the 
affections of common sensibility, itching, tenderness, and pain. 

134. At the orifices of passages into the interior, there are peculiar 
kinds of sensibility connected with the functions of ingestion and eges- 



104 ULTIMATE ELEMENTS OF DISEASE. 

tion ; tliese modified are elements of disease. As examples of such ex- 
cessive sensibility, may be enumerated thirst, craving, nausea, tenesmus, 
and painful micturition ; of impaired sensibility, anorexia, and paralysis 
of the rectum and urethra. 

135. When we come to internal parts, we have only to consider their 
sensibility when exalted by disease. We do not know that they natu- 
rally possess any feeling. Of the ordinary processes, as of the passage 
of food and feces in the alimentary canal, of the movement of the lungs, 
of the heart, and of the blood through the vessels, we are not con- 
scious ; but, under the influence of disease, we become painfully sen- 
sible of several of these motions. This excessive sensibility is de- 
veloped by inflammation, as in pleurisy, peritonitis, meningitis, &c., or 
by irritation by mechanical or other means, as in colic, biliary and 
urinary calculi, gastralgia, perforation of the stomach or intestines, &c. 
It is very remarkable that pain from these, which is perhaps severer 
than any, should arise so suddenly in parts which give no evidence of 
common feeling. 

136. In many instances we are to regard pain merely as a symptom 
to be removed only by means which remove its cause, the lesion which 
produces it (§§ 132, 133) ; but in many cases, on the other hapd, 
although a symptom, it constitutes a chief element of the disease, and 
one against which remedies must be expressly directed. Thus it is in 
neuralgia, gastralgia, nephralgia, colic, dysmenorrhoea, and perforated 
intestine. So long as the excessive pain lasts, all the functions sufi"er 
(§ QQ)^ faintness and exhaustion ensue, and, if no relief comes, the pros- 
tration may be fatal. Here, to mitigate or remove the pain, is a first 
and pressing indication. Again; in some other cases where the pain is less 
severe, it may be very hurtful, by interfering wdth important functions. 
Thus the stitch of pleurisy impedes the breathing ; the pain of tenesmus 
and the irritation of the stomach or windpipe cause efi"orts at straining, 
vomiting, and coughing, so violent that the functions are thereby kept 
in a state of disturbance, and the strength is exhausted. Here it may 
be necessary to treat promptly for the pain on account of its immediately 
pernicious efi*ects. 

137. Remedial Measures. — Where excessive sensibility depends on 
inflammation, antiphlogistic measures will generally soon remove it. 
Where it lingers after the inflammation is out of proportion to it, or is 
independent of it, then anodynes become the chief remedy. The most 
powerful of these is the inhalation of the vapor of ether, above noticed, 
which is fairly applicable to the mitigation or removal of local pain of 
a temporary character. The most potent of fixed anodynes are opium 
and its active principles ; but these have morbid efi'ects (impairing the 
secretions) (§ 70), which sometimes render them less eligible than the 
weaker narcotics, hemlock, henbane, stramonium, belladonna, and Indian 
hemp. The stronger preparations of aconite and its alkaloid are power- 
ful anodynes, and are very valuable as outward applications ; but their 
depressing operation on the heart renders them unsafe for internal 
exhibition. These different anodynes are used both internally and ex- 
ternally. One of the most effectual methods with which I am acquainted, 



DISEASES OF GENERAL VOLUNTARY POWER. 105 

for relieving severe local pain, is the endermic application of morphia ; 
for this purpose a blister is applied to the painful part, and, when fully 
risen, the cuticle is completely removed, and the denuded surface 
sprinkled with one or two grains of a soluble salt of morphia (the ace- 
tate or hydrochlorate) in fine powder, which may be repeated once or 
twice daily, according to the urgency of the pain. The effect is first 
anodyne, then narcotic on the system, with much less than usual of the 
injurious effects of opiates by the mouth. The application loses all 
effect so soon as the blistered surface becomes dry. Counter-irritation 
and warmth are also means of relieving pain. The pain of gastrodynia 
may often be removed by a sinapism to the pit of the stomach ; that of 
colic and dysmenorrhoea by hot fomentations, or bags of hot sand or 
salt, &c. In other cases, painful feelings may be relieved by such pres- 
sure on the part as will counteract tension, and diminish w^ithout stop- 
ping the flow of blood through the part. Painful affections occurring 
with a weak circulation, particularly if intermittent in their attacks, are 
often removed by tonics ; thus neuralgia has been successfully treated 
with quinine and iron, hemicrania with quinia, or liquor arsenicalis. 

138. We are not possessed of equal means of restoring lost sensibility. 
Stimulant applications and frictions are serviceable w^here the defect 
arises from deficiency of circulation in the part ; and strychnia or can- 
tharides given internally, and electricity used topically, 'perhaps may 
have some little effect in exciting the functions of the nerves, but more 
doubtfully in regard to sensation than to motion. 



SECTION ly. 

DISEASED VOLUNTARY MOTION OR EXCITO-MOTION BY THE WILL. 

139. The function by which certain nerves convey the impulses of 
the will to voluntary muscles, may become disordered, and its phenomena 
constitute an element of disease. Some of these have already been 
noticed under the head of diseased irritability (§ 113) ; and it was there 
observed that the error is more commonly in the nervous influence 
which excites the muscles, than in the property of the muscles them- 
selves. This is the case in most convulsive diseases, and in those cases 
of paralysis which depend on injuries of the voluntary nerves, or of 
those parts of the spinal and cerebral system which are the channels of 
volition. A brief illustration of these diseases will suffice to correspond 
with those of diseased sensation. 

DISEASES OF GENERAL VOLUNTARY POWER. 

140. The voluntary motor power may be said to be generally in ex- 
cess^ when the brain is excited by strong emotions or feelings (§ QQ), by 
stimulating liquors (§ 56), and by the hurried circulation of frenzy, or 



106 ULTIMATE ELEMENTS OF DISEASE. 

phrenitic delirium. Hysteria, as usual, can supply like examples. The 
strength and rapidity of movements displayed in hysterical cases are 
sometimes astonishing, yet they are obviously voluntary movements, for 
they are often performed rhythmically, or to a tune, as in dancing. The 
dancing of tarantulism, and the extravagant exertions of the fanatics 
called jumpers, would seem to arise from an erethism of the part of the 
nervous system concerned in voluntary motion. Short of disease, a 
naturally high voluntary power is evinced in the energetic and active 
movements of some persons, who excel and delight in feats of strength 
or agility. Mere muscular strength will not suffice without nervous 
energy to act on it. 

141. G-eneral volition is more or less defective in apoplectic coma, 
stupor from various causes, pressure, congestion, narcotism, &c., where 
other nervous properties are also impaired (§ 129) ; in trance, catalepsy, 
and nightmare ; in a less degree also in cases of lethargy and weakness 
from over-exertion (§ 68). This defect may be sometimes suddenly in- 
duced by terror, surprise, &c. (§ 69), which for a time take away the 
power of motion. Hence the fabulous power of the Gorgon's head ; and 
the signification of the expressions, petrified with astonishment^ motion- 
less with terror^ fascinated, and the like. The muscular power (§ 110) 
is not lost in these cases, but only the influence of the mind over it; 
that is, volition. 

142. Examples oi perverted voluntary power maybe found in chorea, 
delirium tremens, and some analogous affections called hysterical. In 
these, volition may be often also defective (§ 141), but it is not always 
so ; only each act of the will is perverted in its performance. The will 
sets muscles in motion, but the wrong muscles, or too many, too forcibly, 
or irregularly, so that the resulting action is not in accordance with 
the will. 



PARTIALLY D ISE ASED VO LUNT ARY POWER. 

143. We can scarcely point out examples of partial excess of volun- 
tary motion. The convulsive movements of voluntary muscles are 
quite involuntary, and have been noticed under the head of diseased 
muscular action (§ 113); but it was there mentioned that they may arise 
from irritation of the nerves, independent of the will. Hysteria does, 
however, furnish examples of excessive movements of one limb or part 
of the body, so far amenable to mental influence as to be excited and 
timed by ideas in the patient's mind. These cannot be said to be wholly 
involuntary ; but are the results of a wilful impulse, perhaps too strong 
to be easily resisted. 

^ 144. Partial defect of voluntary power is very common, and, like 
local defect of sensibility, may be traced to partial disease of the motor 
(anterior) columns of the medulla and prolongations ; or to disease of, 
or pressure on, a motor nerve in its course ; or to a disordered condi- 
tion of the ultimate distribution of the nerve, or of the circulation sup- 
porting its function. Thus paralysis of voluntary motion in an extre- 
mity or a whole side (hemiplegia), may arise from disease in the optic 



DISEASED VOLUNTARY ACTION. 107 

thalamus or corpus striatum of the opposite side ; these being the chan- 
nels of communication between the cortical seat of the sensorial functions 
and will, and the motory columns and nerves. Lesions of the motory 
(anterior) columns within the spine, may intercept more or less the 
voluntary power of those parts supplied with spinal nerves from below 
the diseased point. Thus a lesion in the lower cervical portion may 
paralyze the upper and lower extremities and whole trunk (except the 
diaphragm, which is supplied by the phrenic nerve) ; a lesion in the 
dorsal or lumbar portion, paralyzes only the lower half of the body 
(paraplegia), or lower extremities. Or the disease may be more partial, 
paralyzing one nerve only, as the portio dura, causing distortion of the 
features ; or the ninth nerve, causing difficult articulation, &c. The 
lesion of the nervous textures here alluded to, may be structural change, 
as tumors, effusions, or hemorrhage, or only an altered state of the 
bloodvessels of the part. Severe cold or continued pressure will impair 
voluntary power in a limb, by checking the free fioAV of blood, which is 
essential to the proper function of the nerves as well as of the muscles. 
Hysteria aifords numerous examples of volition impaired in parts, as in 
loss of voice and power of articulation, retention of urine, paralysis of 
limbs, &c. ; these affections may come on quite suddenly, and as sud- 
denly cease. 

145. Remedial Measures. — Excessive voluntary power is rarely an 
element of disease for separate treatment. As part of the excitement 
of the nervous centres, it may be reduced by sedatives of different 
kinds — depletion, antimonials, and cold to the head, being the most 
effectual, where the excitement is attended with determination of blood; 
morphia, and other narcotics, where the excitement is more purely 
nervous. The violent exertions of maniacs are wonderfully controlled 
by the cold douche to the head, sometimes with nauseating doses of 
tartar emetic. The vehement movements of those excited by fanaticism 
and tarantulism are ended by exhaustion; they might probably be 
checked by a timely ducking with cold water ; which is often successful 
in hysteria. 

146. The treatment of defective volition will consist in means calcu- 
lated to excite the nervous centres, directly or through the medium of 
the circulation. Agents which restore free circulation of healthy blood 
through the nervous centres and branches, generally improve voluntary 
power. Thus a stimulant draught may raise the failing strength of a 
person fainting. By warmth and friction, one who is benumbed with 
cold recovers the use of his limbs. Sleep or rest will restore voluntary 
power exhausted by fatigue. Sudden and powerful mental excitement, 
as by a fright, has been known to restore voluntary power which had 
been long lost. A lady, who for several years had lost the use of her 
lower extremities, was startled by a rat running near her ; having an 
extreme antipathy to the animal, she made an effort, and sprang upon 
a table near ; the power, however, did not remain, for she could not get 
down again. A more permanent cure of impaired volition has been 
effected by the excitement of religious fanaticism, as in the cases of the 
supposed miracles of Prince Hohenloe, Miss Fancourt, &c. As we have 
found that such mental excitement sometimes causes excessive voluntary 



108 ULTIMATE ELEMENTS OF DISEASE. 

motion in liealtliy persons (§ 140), so we perceive that, suddenly applied, 
it may restore it where defective. 

But sometimes volition is defective from pressure on, or congestion in, 
the brain, which prevents the due motion of the blood through it, as in 
plethoric lethargy, or apoplectic coma ; here depletion and derivation 
may sometimes restore the power. In the lethargy of narcotism and 
asphyxia, the volition is often restored by means which excite strong 
sensations, and reflex actions, as dashing cold water on the face and 
chest, ammonia or other stimulating vapors to the nostrils, electric 
shocks, stinging with nettles, &c. The trance or coma of hysteria may 
often be removed by a turpentine injection, or croton-oil purgative, 
which acts both as a revulsive to the vessels and a- stimulant to the 
nerves. 

Perverted volition will require various treatment, according to its 
kind ; that of delirium tremens being corrected by narcotics, especially 
opium ; that of chorea, by nervous tonics, especially iron and zinc. 

147. The treatment of locally diseased voluntary power will gene- 
rally commence with attempts to remove its cause, which we have found 
to vary too much both in seat and nature to admit of an elementary 
statement of remedial measures. Those for defective voluntary power 
comprehend the complex subject of the treatment of paralysis, which 
commonly comprises means calculated to restore to its proper state the 
circulation through the affected part of the nervous system, and some- 
times, also, means which stimulate this part by exciting agents, such as 
electricity, stimulating frictions, and blisters ; and strychnia and can- 
tharides given internally, which are supposed to have a directly stimu- 
lant action on the motory columns and nerves. 



SECTION V. 

DISEASES OF REFLECTED AND SYMPATHETIC NERVOUS 

INFLUENCE. 

148. The nervous property by which various movements and pro- 
cesses connected with organic life are excited, may be disordered, and 
its alterations are remarkable constituents of many diseases. The con- 
tractions of all the sphincters, of the oesophagus, the glottis, the iris, 
the eyelid, and the regular action of the muscles of respiration, seem 
to be sustained, independently of the will, by a nervous influence con- 
veyed by afi'erent nerves from the respective parts or surfaces to the 
spinal marrow, and reflected from it through the efl'erent nerves to the 
muscles connected with these parts. The full establishment of this 
physiological principle we owe to Dr. Marshall Hall. 

149. The increase of this involu7itary excito-motory power is 
instanced in the spasm of the throat, and sometimes of the sphincters, 
in hydrophobia, tetanus, and some hysterical afiections. The hurried 



DISEASED EXCITO-MOTION. 109 

respiration, the convulsive cough, violent retching, and hiccough, which 
are occasionally presented in these and other nervous diseases, may 
also be in part traced to an undue influence of the excito-motory nerves 
of organic life. These actions are sometimes excited by sensations 
(§ 134), as the breathing by feeling of want of breath, cough by tick- 
ling in the air-passages, retching by nausea, &c. ; but it is where either 
there are no such sensations, or where they bear no proportion to the 
violence of the actions, that we are warranted to conclude that the 
excito-motory function is itself exalted. 

A similar exaltation of the excito-motory function, independent of 
sensation and volition, is exemplified in the voluntary muscles, when 
they are deprived of sensation and voluntary motion by disease in the 
brain itself, or cutting off communication between the brain and spinal 
cord, without materially injuring the cord itself (§ 118). Thus, in 
paraplegia from injury of the upper part of the spine, the excito- 
motory power of the nerves of the lower extremities is exalted ; and 
tickling, or mere touching the soles of the feet or legs, will produce 
convulsive motions, although all voluntary power and sensations be 
wholly lost.^ This phenomenon is sometimes so readily produced as to 
be a cause of much disturbance to the patient, the mere touch of the 
bedclothes exciting troublesome startings. The same thing occurs in 
hemiplegia, but less distinctly, as the cerebral influence is rarely here 
so completely intercepted. I have known, however, the convulsive mo- 
tions of a paralyzed limb so violent, in a hemiplegic patient, that it 
was necessary every night to fasten it down to the bedstead to enable 
the patient to get sleep. 

An instance of involuntary excitement of the muscles occurs in the 
symptom of "fidgets," which often arise from irritation reflected from 
the lower part of the intestinal canal, or from the uterus ; and another 
is seen in the sudden retraction of the testicle by the contraction of the 
cremaster, on touching the inner part of the thighs, in disease of the 
kidneys, and other urinary organs. 

150. Under this head, we must also glance at convulsions, which, 
according to Dr. M. Hall's views, and consistently with the phenomena 
of disease, must be referred to an irritation of the true spinal system. 
This irritation may be centric^ as in epileptic and apoplectic convulsions 
from disease in the head, and those from loss of blood ; in which cases, 
the spinal and prolonged medulla being excited, the excito-motory in- 
fluence radiates to the limbs and muscles generally ; or it may be eccen- 
tric^ commencing with irritation of the extremities of some afferent 
nerve, which transfers it to the spinal centre, whence it is again reflected 
generally or partially. Such are the convulsions arising from teething, 
uterine, intestinal, and renal irritation ; and a slighter degree is exem- 
plified in the rigor caused by the sudden impression of cold on the sur- 
face, or by passing a bougie into the urethra of a nervous person. 

* The same phenomenon is exhibited in a high degree in the decapitated frog, in which 
touching the surface excites convulsive movements, A still more interesting illustration 
sometimes occurs in animals or persons whose cerebral power (sensation and voluntary 
motion) is impaired by opium or other narcotics ; spasms or convulsive actions of the 
muscles being induced by tickling or pinching the skin, which shows the excited state of 
the reflex or spinal function. 



110 ULTIMATE ELEMENTS OF DISEASE. 

151. Partial spasms caused by reflected irritation, are exemplified 
in cramp in the legs from acrid matter in the colon, in diarrhoea and 
cholera ; spasm of the glottis from a bone sticking in the pharynx, &c. 
More familiar examples of the same class of reflected irritation are 
found in sneezing from irritation of the nares, winking from irritation 
of the conjunctiva, coughing from irritation of the glottis, retching 
from irritation of the fauces, efforts to evacuate the rectum and the 
bladder from irritation of these parts respectively. But it must not be 
forgotten that all these latter examples are connected with obvious sen- 
sations ; and they imply increased excito-motory influence only in those 
cases in which they are out of proportion to these sensations. 

152. But some of the most remarkable instances of reflected irrita- 
tion are displayed in the involuntary muscles, the heart, and the mus- 
cular fibres of the air-tubes and intestinal canal. Thus, inordinate ac- 
tion of the heart (palpitation) is commonly caused by irritating matters 
in the stomach or intestines, kidneys, or other viscera (§§ 51, 54) ; nay, 
we shall afterwards find, that the heart is liable to be excited by con- 
siderable irritation in any part of the body, as in fever and constitu- 
tional disorder. The spasm of the intestines in colic is induced by re- 
flex irritation resulting from acrid matter in them ; for if it were from 
direct irritation alone, the spasm would only aff"ect the part touched by 
the ofi'ending matter.^ The spasm of the bronchi, so suddenly occurring 
in spasmodic asthma, also sometimes arises from intestinal irritation. 
It has long been supposed, and is still a common opinion, that these 
morbid sympathetic movements are due to the direct nervous connec- 
tion which the great sympathetic nerve establishes between the respec- 
tive organs ; but this supposition assumes, what experiment has not 
proved, that the ganglia of this nerve are either centres of reflection,^ 
or sources of nervous influence, which is still more inconsistent with 
the latest researches. So far as we yet know, the spinal marrow is the 
centre of reflection in these as in all other examples of reflex action 
which we have been considering, although the sympathetic be the me- 
dium of communication.^ 

153. When phenomena of inordinate reflex actions are general or 
extensive, as in convulsions, tetanus, and paraplegia, we must refer them 
to an undue excitement or erethism of the spinal and prolonged medulla ; 
but the more partial examples may arise from similar excitement of a 
small portion of it only, or of the incident (aff'erent) nerve of the part 
which occasions the phenomenon, or of the excito-motory (efferent) nerve 
of the part which exhibits the phenomenon. 

If we seek to know the causes of this excitement, we shall find that, 
as in excess of other vital properties, it is sometimes referable to an 
increased flow of blood through the spinal marrow or its nerves, or the 
branches of the sympathetic nerve. Thus the early stage of inflamma- 
tion of the spinal cord, or of its sheath, is attended with convulsions or 
tetanic spasm. It is very probable that the spinal excitement (convul- 
sions) occurring in epilepsy and apoplexy, is in part due to the flow 

1 Muller's Physiology (by Baly), p. 737. 2 Volkman, Miiller, p. 738. 

3 [Valentin, Carpenter's Human Physiology, p. G74, 5th Am. Ed.] 



DISEASED EXCITO-MOTION (rEFLEX). Ill 

through the medulla being increased in proportion as that through the 
brain is impeded ; a consideration of the causes of convulsive paroxysms, 
and of the distribution of the vertebral arteries, much countenances 
this supposition. But in many cases, the excitement seems to be of a 
more direct nature. Strychnia, in a poisonous dose, excites the medulla 
so speedily, causing tetanic spasm, that its effect can scarcely be due to 
increased flow of blood. So, too, we know that mechanical irritation 
of the spinal marrow, or of its nerves, will cause convulsive motions ; 
and we find this exemplified in the effect of tumors and spicula of bone 
in the spinal canal, in the head, or in the course of nerves. But no- 
thing exhibits this element of nervous irritation (apart, so far as is yet 
known, from vascular influence) so fearfully as traumatic tetanus. The 
irritation here begins in a distant nervous branch, and is propagated to 
the medullary centre, the excito-motory function of which at length 
exhibits a state of erethism, which destroys life either directly by tonic 
spasm (§ 114) of the muscles of respiration, or by exhaustion. An- 
other cause, which may be fairly assigned for increase of the involuntary 
excito-motory property, is accumulation by rest. This causes the aug- 
mentation of this property in the medulla in narcotism from opium, and 
in injuries of the spine (§ 149), which suspend the exhausting influence 
of volition on the whole or part of the marrow, in which the nervous 
energy therefore accumulates, and becomes unusually abundant. There 
is a natural increase of this property in sleep, which, by suspending the 
sensorial functions, augments the energy of those of the medulla ; and 
this accession of power, which maintains the movements of respiration 
during sleep, also disposes to the occurrence of spasmodic attacks at this 
time ; hence the fits of epilepsy and asthma commonly come on during 
sleep. So likewise sedentary habits, and too much indulgence of sleep, 
may cause an accumulation and morbid excess of involuntary nervous 
power, and develop convulsive and spasmodic symptoms, which are the 
result of its overflow. 

154. Defect of the reflex or involuntary excito-motory function is 
exemplified in the paralysis which affects the sphincters, the eyelids, the 
muscles of respiration, and others whose normal action depends on this 
function (§ 148). When this is generally and considerably impaired, 
the result will be fatal ; because the respiration, deglutition, and other 
actions essential to life, suffer. It is by affecting these actions that apo- 
plectic coma and narcotism prove fatal ; and the state of sinking from 
excessive weakness or depressing causes, also exhibits the failure of the 
reflex power, when the urine and feces are voided involuntarily, and the 
breathing is irregular and gasping, being forced by voluntary effort. 
From failure of the same power, coughing and expectoration become in- 
efficient in clearing the air-passages of mucus ; hence the bronchial and 
tracheal rattles which precede death. As these movements are the last 
to fail, so, in recovery from asphyxia, syncope, and other similar states 
of partially suspended animation, the actions connected with the reflex 
function are the first to return with the restoration of life ; and thus vo- 
miting, coughing, and sneezing, are among the early signs of reaction. 

A failure of this function, similar in kind, but less in degree, is ex- 



112 ULTIMATE ELEMENTS OF DISEASE. 

hibited in all states of extreme debility, whether from excessive fatigue 
or excitement (§§ 64, 65)^ or from directly depressing or sedative influ- 
ences, as in adynamic fevers (§ 105). A person in this state is too 
weak to sleep ; for the medulla partaking of the general exhaustion, 
cannot mainta^in the respiration without assistance from voluntary efforts. 
Hence the feeling of oppression and the frequent sighing, which banish 
all repose ; or, if sleep do occur, it is disturbed by startings and fearful 
dreams, occasioned by the painful sensations of imperfect breathing. 

155. Remedial Pleasures. — As with other instances of exalted nervous 
function, so with excessive reflex action^ when dependent on inflammation, 
or determination or congestion of blood in the medulla, the remedies for 
these are appropriate against this effect; and the same measures in 
smaller degrees are often useful in hysterical affections, when these occur 
with fulness of habit and spinal tenderness. In case of irritation of 
the nervous centres, more purely nervous, as that of tetanus, hydropho- 
bia, poisoning with strychnia, &c., a narcotic or sedative, which may 
lower the exalted function, is the desideratum. We possess some agents 
which efiiciently reduce the power of the spinal system, and cause general 
relaxation of the muscles, such as hydrocyanic acid, woorara, Indian 
hemp, resin, and conium ; these drugs may themselves destroy life by 
arresting the function of the medulla oblongata in maintaining respira- 
tion ; but this very poisonous action, and the sedative effect which one 
(hydrocyanic acid) also has on the heart, render the remedy almost as 
dangerous as the disease.^ For slighter irritation of the medulla, how- 
ever, these medicines, in moderate doses, and a few others like them, are 
often beneficial. Thus hydrocyanic acid is a very efficacious remedy in 
vomiting, nervous palpitation, and hiccough ; it is likewise useful in con- 
vulsive cough, in which, however, the extracts of belladonna and stramo- 
nium are still more effectual, as they also are in spasmodic asthma. 
The same medicines and opium are often beneficial in relieving the 
spasms of colic, dysentery, and dysuria. 

Some medicines, which act as stimulants to the heart and vessels, and 
to the cerebral functions, seem to operate as sedatives to the medullary 
system ; these are the stimulant antispasmodics ; such as ether, ammo- 
nia, musk, essential oils, gum resins, creosote, alcohol, &c., which are 
useful remedies in spasmodic and convulsive affections, in weak sub- 
jects without inflammation. They probably operate by giving vigor and 
equality to the circulation, and by preventing undue determination and 
congestion of blood in the nervous centres. External heat and counter- 
irritation act in a similar way. 

There is another class of remedies which have some power in reducing 
the excitability of the spinal excito-motory system ; namely, tonics, 
especially those prepared from metals ; but the operation of these is 
gradual, and therefore probably indirect. The sesquioxide and other 
preparations of iron are eflrteacious in chorea, and perhaps in the more 
chronic forms of tetanus. Nitrate of silver, sulphate and oxide of zinc, 

1 From the late accounts of Dr. O'Shaughnessy and others, the resin of the Indian 
hemp seems to be more powerful than any other remedy in relaxing tetanic spasm, and in 
at least alleviating the symptoms of hydrophobia. 



DISEASED EXCITO-MOTION (REFLEX.) 113 

and sulphate of copper, have been found to diminish the attacks of epi- 
lepsy, hysterical convulsions, spasmodic asthma and cough, and other 
convulsive affections. The more obvious operation of these affections 
is on the vascular system, to which they prove astringent and tonic, 
and it is uncertain whether their beneficial action in nervous diseases is 
of this kind only, equalizing the circulation, or whether they exercise 
any more direct influence on the nervous system. The same question 
is open with regard to certain regiminal means which are effectual in 
reducing nervous excitability, such as cold bathing, country air, and 
change of air, and exercise. The latter, however, no doubt may be 
useful by exhausting the superfluous nervous power (§ 153) by another 
channel, voluntary motion. 

The chief remedies to sustain defective or failing medullary function 
are stimulants, narcotics, and various strengthening measures. Thus a 
fatal state of sinking has sometimes been removed by the free adminis- 
tration of ammonia, ether, brandy, and other stimulants ; and the best 
proof of their beneficial operation is when they procure refreshing sleep, 
which in itself is a source of renewed power. Narcotics would also seem 
to be indicated, but in an extreme condition of weakness their indiscri- 
minate employment is hazardous, as they may paralyze the little remain- 
ing power, and lull the patient into the sleep of death. They should 
be preceded by, or combined with, stimulants ; and those narcotics 
should be selected which have the least depressing action, such as opium. 
Other means must not be neglected to sustain the power restored by 
stimulants, especially suitable nourishment frequently administered in 
a liquid form. 



EEFLECTED, OR SYMPATHETIC SENSATIONS. 

156. Clinical observation teaches us that not merely motory impres- 
sions, but those also which cause sensations, may be reflected, so that 
when the impression is made on one part the sensation is experienced 
in another. I do not allude to the fact that a stroke on the nervous 
trunk produces feelings referred to its branches, but I advert to impres- 
sions on the ultimate distribution of one nerve producing sensations in 
parts supplied by another nerve, or by another branch of the same 
nerve. The following are examples of this kind : Touching the exter- 
nal auditory meatus causes a tickling sensation in the glottis. A cal- 
culus in the bladder produces pain referred to the extremity of the 
penis. Ascarides in the rectum cause itching of the anus, and some- 
times of the pudenda. Congestion of the liver sometimes is accompanied 
by pain in the right shoulder-blade ; and a disordered state of the stom- 
ach, occasionally with pain in the left shoulder-blade. The pains of 
angina and gastrodynia often extend to the whole chest, and the former 
especially radiates to the left arm. Severe frontal headache is almost 
instantly caused in some persons by acid ingesta, in others by eating 
ice. Irritation of the intestines, as in cholera and colic (especially 
painter's colic), frequently causes pain and tenderness in the legs and 
feet, even when there has been no cramp or other excito-motory pheno- 
8 



114 ULTIMATE ELEMENTS OF DISEASE. 

mena. Temporary neuralgic affections, generally described as spinal 
irritation and cutaneous sensibility, seem to be due to similar causes. 

In these and other instances that might be cited, the sensations can- 
not be referred to direct nervous communication, but to an influence 
reflected, probably, from the spinal centre only. 

The sympathies subsisting between some organs are very remarkable, 
and none more so than between the breasts and the uterus. Applying 
the infant to the breast often induces uterine pains in women recently 
delivered ; and the catamenial discharge has been excited in some 
instances by stimulating applications to the breasts. 

157. The remedies most effectual in relieving reflected sensations 
are — 1st, those that remove their irritating cause ; and 2d, those that 
deaden sensibility (§ 137), anodynes. The peculiar efficacy of trisni- 
trate of bismuth and hydrocyanic acid in relieving gastrodynia and some 
kinds of angia, is, however, not explicable by any narcotic quality, and 
is probably due to an influence exercised on the power of the nerves to 
transmit sympathetic irritations. These morbid sympathies are often 
exalted in common with other nervous properties (§§ 126, 148), by 
weakness or irregularity of the circulation (§ 153) ; and are generally 
diminished under a tonic plan of treatment, especially with the metallic 
tonics, preparations of iron, nitrate and oxide of silver, sulphate of 
copper, arsenic, &c. 



SECTION YI. 

DISEASES OF SECRETION. 

158. The power of secretion appears to be a vital endowment of the 
ultimate cells or molecules of secreting structures.^ It is uncertain 
whether the process comprises the formation as well as the separation 
from the blood of the peculiar matter of the secretion. In the case of 
the urine and bile, it would seem that they may be formed in the blood 
without the aid of the secreting organs ; for urea is found in the blood of 
animals whose kidneys have been prevented from acting by ligature of 
their bloodvessels, or by extirpation ; and both urea and some of the 
principles of the bile (coloring matter and cholesterine), are found in the 
blood and in various parts of the body when the kidneys and the liver 
respectively have been disabled by disease. But whether the secreting 
structures assist in the formation, or only effect the separation of the 
matters which they eliminate, their elective power is equally a peculiar 
attribute of life, and is at present inexplicable by any physical or che- 
mical law. I have, for the last twenty years,^ advocated the opinion 
recently advanced by Dumas and Liebig, that the formation of the prin- 
ciples of the chief secretions takes place through chemical affinities, 

■ Miiller, De Glandularum penitiori structura. Henle, Allgemeine Anatomie. Goodsir, 
Trans. Royal Society of Edinburgh, 1842. Bowman, Phil. Trans. 1842. 

2 In a thesis, De Sanguine ejuaque mutationibus, Edin. 1824. See also Med. Gaz. Sep- 
tember and October, 1835. 



DISEASES OF SECRETION. 115 

especially those of the absorbed oxygen and the constituents of the blood, 
controlled by vital agencies ; but this view leaves still as a vital property 
the power which the liver has to separate bile; the kidneys, urine, mu- 
cous membranes, mucus, &c. 

We are thus led to consider secretion as a peculiar property of the 
secernent structures, just as irritability is of muscular fibre (§ 110) ; and 
as such its disorder constitutes a primary element of disease. In doing 
this, we avoid the hypothesis of some physiologists, who ascribe secre- 
tion to nervous influence, a notion by no means accordant with nume- 
rous facts. 

159. In reviewing the disorders of other vital properties, we have 
found that many of them are plainly referable to changes in the supply 
of blood to their respective textures (§§ 113, 127, 131, 133, &c.). The 
same cause may be found still more decidedly to operate in producing 
variations in the process of secretion. The blood being the material 
from which the secreted matter is supplied, variations in the quantity or 
quality of the blood will surely alter the quantity or quality of this pro- 
duct. Thus when an increased flow of blood takes place to a mucous 
membrane, its secretion is increased, and sometimes rendered more acrid 
than usual ; whilst a congested state of the same membrane may impair 
the secretion. Hence the most common causes of altered secretion are 
those which operate on the sanguiferous system and its contents. 

160. But afi'ections of the nervous system, and of the mind, which 
acts through that system, may also influence the secreting process, as 
shown by the mouth watering at the sight or thought of a good meal ; 
the bilious diarrhoea that mental agitation will cause in some persons ; 
the large flow of limpid urine after nervous agitation ; the tears excited 
by grief or other strong emotion ; the unwholesome quality of a nurse's 
milk when she is in a state of anxiety or apprehension. We do not 
know whether these influences act by altering the flow of blood (§ 159), 
or by more directly modifying the vital property of the secreting organ 
(§158). 

161. The importance of this element of disease may be estimated, 
from the ubiquity of the process of secretion, which includes both exere- 
mentitious (only to be voided out of the system), and recrementitious pro- 
ducts (those concerned in digestion, assimilation, and nutrition), and 
also from the extent of its efiects in relation both to the destination of 
the secretion, and to the blood from which it is separated. These may 
severally be excessive, defective, and perverted. 

162. Excessive secretion of any kind, whether bile, urine, mucu&, 
&c., may weaken by the drain which it causes from the mass of blood 
(§§ 28, 71) ; and this effect will be in proportion to its quantity, and 
especially to the animal matter which it contains. Thus an excessive 
secretion of bile weakens more than that of thin mucus. Eut each 
secretion may have peculiar effects connected with its oflSce and com- 
position; and these effects may be forwards, on the parts to which the 
secretion goes, and backwards, on the organ which secretes it, and on 
the blood from which it is formed. 

163. The forward eff'ects of an excessive secretion of bile depend 
on its stimulating properties. It irritates the intestinal tube, causing a 



116 ULTIMATE ELEMENTS OF DISEASE. 

bilious diarrhoea or cholei-a. The symptoms of this consist in an ex- 
aggeration of those properties of the alimentary canal which have al- 
ready been described as elements of disease. Thus the bile irritating 
causes increased irritability (§ 113), and more rapid motion of the mat- 
ter through the tube ; pain from exalted sensibility (§§ 134, 135) ; vo- 
miting, straining, and cramps, from exalted excito-motory function (§§ 
149, 151) ; profuse mucous secretion from excited secernent function (§ 
162). An excessive secretion of mucus in the intestines may cause only 
simple diarrhoea; but in the bronchi it may occasion dyspnoea and cough, 
and, if not expectorated, may suffocate. Excessive secretion in the 
stomach may cause pyrosis, or water-brash, the liquid being sometimes 
acrid, and may occasion nausea and vomiting, as well as eructation. The 
excessive discharges from secreting organs generally may amount to a 
flux, or profluvium ; and those from internal inclosed serous surfaces or 
cellular texture, constitute various dropsies. These produce diff'erent 
effects according to their situation. 

164. But excessive secretion may also have effects hachwards^ on the 
organs^ and on the hlood from which it proceeds. Excessive secretion 
often weakens the vital properties of the organ^ so that, in its proper 
function, it subsequently becomes torpid. Thus after diarrhoea, the 
bowels often become torpid from defective secretion. So, too, in cases 
where an excessive secretion continues for a long time, it generally is 
impaired in its quality from a similar cause. 

165. Excessive secretions, if abounding in animal matter, may not 
only reduce the mass of the blood, but also effect its composition. 
Thus bile and urine, which differ much in composition from the blood, 
if separated in unusual proportions, must leave the blood modified. 
Urine contains a great preponderance of azote ; and its excessive form- 
ation from the principles of the blood would leave a predominance of 
hydrogen and carbon in this fluid. The bile, again, abounds in hydro- 
carbon, the copious removal of which would leave a superfluity of azote. 
It may be objected to this statement, that, according to the opinion of 
some chemists, the urine and the bile are not formed from the constant 
elements of the blood, but from materials derived from the food, and from 
the decay or transformation of the tissues. To this it may be replied, that 
this opinion is at present no more than hypothetical; and should it prove 
to be true, it would not affect the undoubted fact, that the secretions 
of the liver and of the kidneys are intended to balance one another, 
and the removal of carbon from the lungs ; and that, whether the mate- 
rials from which these eliminating processes are supplied be the prin- 
ciples of the blood itself, or the decayed constituents of tissues, or mat- 
ters derived from the food, the co-operation of all these processes will 
be generally required to maintain a uniformity in the composition of 
the circulating fluid ; so, too, if one of these processes is more active than 
the others, the blood must suffer by the excess of those matters which 
the less active processes allow to accumulate in it (§§ 68, 69). A clini- 
cal illustration of this position may be found in cases of bilious diarrhoea 
or cholera. This flux of bile is either accompanied by a highly loaded 
state of the urine, or by fever ; in the latter case, the fever does not 
subside until the urine becomes very copious, or deposits an abundant 



EXCESSIVE SECRETION. 117 

sediment. The most probable interpretation of tbis fact is, that the exces- 
sive secretion of bile disorders the composition of the blood; so long as 
the kidneys rectify this disorder by separating in greater abundance the 
solid contents of the urine, no fever results ; but if the kidneys fail in 
this task, fever ensues, and continues until they accomplish it ; then a 
free secretion and copious deposit are symptomatic of the decline of the 
fever. 

166. The remedial measures that are serviceable in cases of excessive 
secretion, well illustrate the view that has just been given of the balanc- 
ing office which the secretions all fulfil. In so far as excessive secretion 
is dependent on the quantity and quality of the blood (§ 159), the treat- 
ment should be addressed to this element; by depletion, derivation, and 
evacuation, in cases of congestion or determination of blood ; and in 
such cases, the excessive secretion should not be hastily checked, as it 
may be a natural means of relief; nay, in some cases, it may be most 
speedily arrested by means which for the time increase it ; thus a large 
dose of calomel will sometimes, after first purging, stop a bilious diarrhoea 
connected with an engorged liver, which astringents fail to check. But 
where the excessive secretion proceeds more from nervous and other 
sources of irritation (§ 160), and causes weakness and disturbance of the 
functions, it becomes a more immediate indication to check it. Secre- 
tions are to be diminished by means which act as general tonics or as- 
tringents (§ 124), and by others which operate only on particular organs. 
Of the former class are cold applied to the part, and common astringents, 
such as alum, superacetate of lead, sulphates of zinc and copper, gallic 
acid and tannin, and substances which contain them, as nutgalls, oak 
bark, rhatany root, catechu, &c., mineral acids, &c. These act most 
surely by direct application, as in their use for diarrhoea, leucorrhoea, 
&c. ; but they seem to have some effect also through the medium of the 
circulation, as, when taken internally, they reduce the secretion in the 
air-passages and skin. Of the agents which, without a general astringent 
effect, more specifically diminish the secretion of particular organs, may 
be mentioned opium, which remarkably lessens the secretion of the liver, 
and sometimes that of the kidneys. 

If an excessive secretion have already caused febrile disturbance, great 
advantage will be found to result from the use of means which increase 
other secretions, and thus restore the balance before explained (§ 165). 
Thus in bilious cholera, saline diuretics and diaphoretics are highly ser- 
viceable. In renal irritation, with copious secretion of lithic acid, blue 
pill, which augments the secretion of bile, is often beneficial. These 
means may be supposed to operate partly as derivants; but the manner 
in which they remove the febrile irritation, after the reduction of the ex- 
cessive secretion, renders it most probable that they act also by remov- 
ing from the blood dregs left by the inordinate separation of the matter 
of the single secretion which has been in excess (§ 165). No practical 
physician can doubt that we possess medicines which often augment the 
secretions of particular organs (mercury, that of the liver and salivary 
glands, colchicum that of the kidneys, &c.), yet there is a limit to the 
operation of these agents ; but this limit may be increased by simulta- 



118 ULTIMATE ELEMENTS OF DISEASE. 

neously acting on other organs which maintain the balance. Thus in 
any disturbance of the secretions, especially if it continue long, combina- 
tions of medicines are much more useful than those fulfilling one indica- 
tion only; and thus experience has sanctioned the practice of conjoining 
mercurials with diuretics, and antimonials with salines, &c. 

167. Secretions may become defective in consequence of a weak- 
ened state of the whole circulation, or of that of the secreting organ, as 
in the case of exhaustion from previous excitement (§ 164). Or they 
may be impaired by depressing influences which paralyze the vital 
powers, as in the case of morbid and narcotic poisons (§§ 56, 64, 65) ; 
or they may be checked by agents which increase the tonic contraction 
of the vessels of the part, as cold (§ 77) and astringents, or of the whole 
sanguiferous system, as in the case of the hot stage of fevers (§§ 85, 421). 

Defective secretion of any natural or habitual discharge (§ 70), may 
cause a fulness of the bloodvessels ; a general fulness, if the secretion 
be naturally copious; a local fulness, if it be trifling in quantity. Thus 
defective secretion of urine or bile may cause general plethora, or ex- 
tensive local congestions, which may end in dropsical efi"usions, fluxes, 
hemorrhages, or inflammations. Diminished secretion of tears or saliva 
would merely cause fulness and dryness of the parts immediately con- 
cerned. 

The morbid effects of defective secretion may be both forwards, on 
the parts for which the secretion is intended, and bachvards, on the 
organ and on the blood from which it should be eliminated (§ 162). 

168. Defective secretion of bile causes disorder in the latter stages of 
digestion. The neutralization of the acid in the chyme, and the separa- 
tion of the chyle, to which the bile seems to contribute, are imperfectly 
performed ; sometimes colic and diarrhoea, sometimes costiveness, result 
from the defect. Deficient secretion of mucus in the intestinal canal and 
bladder would expose their membranes to more irritation from their con- 
tents. Probably deficient secretion of mucus on the respiratory mem- 
brane may lessen the facility with which the air and the blood act on 
each other. Insufiicient secretion of cerumen in the ear, or of saliva in 
the mouth, impairs respectively the hearing and the process of mastica- 
tion. A w^ant of synovia in the joints, has been supposed to be a cause 
of their imperfect motion and subsequent inflammation. 

169. The effect of defective secretion in causing congestion of its re- 
spective organ, has been already noticed ; the concomitance of conges- 
tion with defective secretion, in the case of the liver, the kidneys, and 
mucous membranes, is well known ; but either may be viewed in the 
light of both cause and effect. 

170. The most remarkable of the hachivard effects of defective se- 
cretion are instanced in case of the excretions (§ 70). The distinctive 
materials of the secretions of urine and bile appear to be positively 
noxious, and poison the system if not separated from the blood. Thus 
the sudden suppression of urine or bile causes typhoid symptoms, ex- 
treme depression, and coma, which speedily end in death; and in such 
cases, urea, or the coloring matter of the bile, has been found in various 
organs. Where the suppression is incomplete, the poisoning process is 



DEFECTIVE SECRETION. 119 

more tardy ; various functional and visceral derangements are produced, 
such as delirium, or lethargy, dyspnoea, palpitation, vomiting, diarrhoea, 
dropsical effusions, structural degenerations, &c., which always cause 
injurious effects, if the defective excretic^ be not restored. But the 
amount of these effects will depend on the extent, and especially on the 
suddenness, of the diminution of the excretion; and it is very remark- 
able when it is very gradual, how little disturbance it may for some time 
induce. In these gradual cases, still more remarkably than in those of 
more sudden suppression, some of the excrementitious matters may be 
detected in the blood and in other fluids and solids of the body. Thus 
in some structural diseases of the liver, the color of the bile becomes 
manifest, first in a yellow, and by accumulating in a deep greenish 
color in all the textures, constituting the yellow and the black jaundice. 
In granular degeneration of the kidneys, in which scarcely any urea is 
excreted by these glands, this principle is found in the blood and various 
fluids of the body. In the case of a patient of mine, affected with as- 
cites from disease of the heart, liver, and kidneys, Mr. Garrod obtained 
nearly four grains of nitrate of urea from an ounce of the peritoneal 
fluid, and a considerable quantity of bright yellow solid matter, probably 
bilious. In other cases, I have known the fluid of ascites and anasarca 
from diseased kidneys, emit a decidedly urinous smell, and exhibit on 
analysis easily appreciable quantities of urea. One of my pupils, Mr. 
Palmer, detected urea in the serum contained in the ventricles of the 
brain, in a case of fatal apoplexy from granular kidneys and diseased 
heart. 

171. The excretions are defective in many idiopathic and symptoma- 
tic fevers ; and there can be little doubt that many of the constitutional 
effects of these fevers are in great measure due to this important element. 
The positively noxious properties which excrementitious matter retained 
in the blood is known to possess (§ 170), must be taken into account 
when we attempt to explain the states of constitutional irritation and de- 
pression, with perversion of functions, which fevers so generally present. 
[One of the most interesting facts connected with the pathology of the 
epidemic fever which prevailed in Edinburgh in 1843, was the discovery 
of urea in the blood and serous fluid of the ventricles of the brain, in 
some of the patients affected with cerebral symptoms. " The existence 
of urea in the blood," says Mr. M. W. Taylor {Scottish Med. Gtaz. p. 
281), " in other cases, has been inferred from the occurrence of disor- 
ders of the nervous centres, which we know to be the consequence of its 
undue accumulation in the circulation. These phenomena have been 
observed in those cases in which, from some cause or other, the daily 
discharge of urine has undergone material diminution."^ — C] The 
changes in the blood, manifest in some such cases by its fluidity and by 
petechial appearances, may also be in part referred to defective elimina- 
tion of effete matter f and it is when the secreting organs recover their 
power, and a diarrhoea occurs, or a copious discharge of highly loaded 

» [Clymer on Fevers, p. 92, Phila. 1846.— C] 

2 Purpura I have found to be often connected -with hepatic congestion, and imperfect 
excretion of bile, and to be most effectually removed by remedies which promote the re- 
storation of the proper secretion. 



12;Q' ULTIMATE ELEMENTS OF DISEASE. 

urine, that these appearances cease. It is very probable that severe 
mechanical injuries or shocks (§ 52), and animal and other poisons (§§ 
85, 105, 57, &c.), operate by thus injuring the vital powers by which 
the blood is continually purifie|l from its own noxious products ; and that 
this is a part of their mode of action, seems almost certain from their 
effect in suppressing or impairing the natural excretions. Accordingly, 
in such cases, urea has sometimes been detected in the blood. 

There can be little doubt that a morbid element, which in its extremes 
acts so injuriously as to cause serious disorder, and even speedy death, 
must in slighter degrees be an important cause and constituent of dis- 
ease ; and I believe that gout, rheumatism, and many cachectic states 
leading to diseases of nutrition, degenerations, dropsies, &c., are essen- 
tially connected with defective excretion. 

172. Remedial Measures. — Defective secretion may be caused by 
deficient or excessive supply of blood to the part, as in various cases of 
anaemia, congestion, and inflammation (§ 159). In such cases it must 
be treated by the proper remedies for these conditions ; thus stimulants 
may restore secretions scanty through a defective supply of blood ; and 
depletion and derivation may be the best remedies, when they are stop- 
ped by inflammation or congestion. 

173. But sometimes the first disorder is in the secreting structure it- 
self (§ 158), and may best be removed by agents which specially increase 
the respective secretions, which common stimulants will not do. Thus 
mercury increases the secretion of the liver ; colchicum, nitre, and other 
diuretics, that of the kidneys ; croton oil, jalap, sulphate of magnesia, 
and other purgatives, that of the intestines ; and this they do, however 
introduced into the system, whether by the mouth, through the skin, or 
injected into vessels or textures. These are important practical facts, 
however difficult they may be to explain ; and their application to re- 
store defective secretions is abundantly obvious. 

174. But these specific stimuli of the secreting organs (§ 173), if used 
in excess, or too long, may not only cause general weakness, but also 
exhaust the vital properties which they excite (§ 159) ; and the result 
may be a diminution either of the secreted fluid, or of its most character- 
istic constituents. Hence the long or excessive use of mercury causes 
torpidity of the liver ; that of purgatives, imperfect action of the bowels ; 
that of diuretics, scanty urine, or albuminous or watery urine, defective 
in urea. These facts point out the expediency of intermitting the use of 
these agents, and of alternating or conjoining them with others calcu- 
lated to improve the vital properties of the textures generally, which 
may often be effected by the medicines called tonic, and by regiminal 
means which improve and equalize the state of the circulation (§ 124), 
and preserve the digestive and assimilative functions in the best order. 
In illustration of this position, I may refer to the acknowledged advan- 
tage of giving bitters with or after mercurial courses ; chalybeates with 
or after saline aperients and diuretics, when these are long used ; and 
these additions, which alone, or used at first, would check the secretion to 
be increased, now sustain it and render it permanent. Some medicines 
which are inferior in efficacy to those already named, are yet, in some 
instances, more eligible for chronic cases of defective secretion; because 



PERVERTED SECRETION. 121 

they are less exhausting, and combine some measure of tonic influence 
with that of increasing the secretions. As examples of this kind may 
be named taraxacum, preparations of iodine, sarsaparilla, nitric, and 
nitro-muriatic acids. Courses of these medicines are sometimes of great 
efficacy in keeping free the secretions after they have been restored by 
more powerful means (§ 173) ; and they likewise often improve the 
functions of digestion and nutrition. 

175. Where defective secretions are not readily restored, the forward 
disorder (§ 168) arising from their deficiency, may be sometimes com- 
pensated by artificial substitutes. Thus, in defective secretion of bile, 
the action of the intestines has been promoted by exhibiting ox gall. 
Aloes and soap combined have been thought to supply the place of bile 
in some cases. Toasted bacon at breakfast has been supposed to have 
a similar efi*ect ; but it more probably excites the liver to increased 
secretion, as other fat matters do. Imperfect lubrication of the throat 
and larynx, and other mucous membranes, from defect of mucus, may 
be remedied by mucilaginous and demulcent matters. A dry state of 
the skin may be relieved by applications of oil or honey. 

176. Perversion of secretion often accompanies excess and defect 
of this process. In febrile diseases, the secretions of the kidneys and 
alimentary canal are altered as well as diminished. Inflammation and 
determination of blood change as well as increase the secretion from 
mucous membranes, rendering it more saline, and sometimes albuminous. 
The urine exhibits remarkable changes in quality ; full living, stimulating 
beverages, and irritations of the digestive organs or kidneys, rendering 
it unusually strong and acid ; whilst low diet, and other causes of weak- 
ness, generally make it pale and alkaline. Out of these morbid con- 
ditions may arise various further decompositions, with sediments and 
calculous concretions of difi'erent kinds (§§ 51, 53). Concretions are 
likewise formed from an altered state of the bile. The alvine secretions 
are greatly modified by various febrile and cachectic diseases, being 
altered in color, and unusually offensive in odor. The perspiration is 
also sometimes changed ; thus it is very acid in rheumatism, and fetid 
in delirium tremens. 

177. Secretions which serve particular purposes, when altered may 
become unfit for these, and thus cause disorder ; thus a thin acrid mucus 
irritates, instead of protecting, the membrane which secretes it, as in 
coryza and mucous diarrhoea ; a viscid dry mucus clogs up and obstructs 
tubes which it was intended to lubricate ; altered gastric juice causes 
indigestion ; sebaceous matter of the skin may accumulate in its follicles, 
and cause irritation and inflammation, &c. 

178. The remedies for perverted secretions (§ 176) are usually those 
which likewise increase secretion (§§ 172, 173). Thus depraved secre- 
tions of the intestinal canal are often satisfactorily altered by continued 
purging; a turbid state of the urine is sometimes removed by diuretics; 
too thick a state of the mucus of the air-passages is modified by expec- 
torants, &c. But where the change depends on altered circulation in 
the part, the remedies must be suited accordingly. In some cases, tonics 
restore a healthy state of secretions ; and in most instances of long-con- 



122 ULTIMATE ELEMENTS OF DISEASE. 

tinued perversion, tonics may be advantageously combined with medi- 
cines which increase secretion (§ 174). Such a combination is presented 
in most of those remedial agents which have obtained the appellation of 
alteratives^ and which would seem to be especially suited to oppose the 
diseased element under consideration, if they really possessed the virtues 
ascribed to them. 

Nutrition is also effected by the property of secretion (§ 158) ; but 
inasmuch as its changes cannot be understood without a previous know- 
ledge of the blood and its constituents, and involve the complex subject 
of structural disease, their consideration will be deferred. 



SECTION YII. 

DISEASES OF THE CONSTITUENTS OF THE BLOOD. 

179. The pathological elements (§ 107) which we have hitherto con- 
sidered, are those of the vital properties of the elementary solids. We 
now proceed to examine the morbid changes of the blood. These, like 
those of th-e solids, may be often traced to individual elements, of which 
the blood is composed, the changes of which must be viewed as ultimate 
elements of disease, and are therefore properly included in the present 
division. But as the blood also operates as a whole, compound, indeed, 
in itself, but simple in its influence, on vital functions and structures, it 
forms a proper connecting link between ultimate and proximate elements 
of disease. So, also, inasmuch as it is in some respects an organized 
compound, the materials of which are changed, together with its func- 
tions, and contributes to the production of change of structure in the 
solids of the body, the consideration of its changes will be a proper 
introduction to that of alterations in the circulation, which induce 
change of structure, and thus lead to structural diseases themselves. 

180. We have found that blood is the support of all the vital proper- 
ties ; and in describing their variations, we have been obliged to refer 
frequently to differences in the supply or quality of this fluid, both as 
causes and as consequences of these variations (§§ 113, 127, 131, 159, 
&c.). We have now to examine the properties of the blood itself, and, 
first, those which are most elementary, or referable to its respective 
constituents. 

The circulating blood consists of red particles, colorless globules, and 
liquor sanguinis ; but as the latter is compound in function as well as in 
constitution, it is necessary to specify its chief constituents. We have, 
then, to consider — 

1. The red particles, 

2. Fibrine and colorless globules, 

3. Albumen and other dissolved 
animal matters, ) in excess, defect, and alteration. 

4. Oil, 

5. Salts, 

6. Water, 



CHANGES IN THE BLOOD — RED PARTICLES. 123 

181. The average natural proportions of the chief constituents of the 
blood, according to Lecanu, and adopted by Andral and Gavarret as a 
standard, are 127 red globules; 3 fibrine ; 72 animal matter in the 
serum ; 8 salts ; 790 water. ^ 



RED PARTICLES. 

182. The red blood-disks appear to be the part of the blood on which 
its vivifying and calorific properties chiefly depend. Thus Prevost and 
Dumas found that animals bled almost to death could be restored by in- 
jecting into their veins a mixture of red particles and serum, even when 
the fibrine had been removed ; yet the serum alone failed to produce any 
such efi'ect. It is therefore to be supposed that the red particles are the 
part of the blood required in transfusion in cases of hemorrhage. An- 
dral, Gavarret, and Delafond, remarked that, in domestic animals, the 
vigor and beauty of the animal were proportioned more to the amount 
of red particles in the blood of the animal than to any other constituent ; 
and that improvement of a breed by crossing was marked by an in- 
creased proportion of this element.^ The red particles are supposed, 
by Liebig, to be the means by which oxygen is carried throughout the 
circulation, and brought to act on the various textures. Their propor- 
tion varies considerably in health ; in men, it may be stated generally 
at from 120 to 140 in 1000 of blood ; in females, it is usually from 10 
to 20 less. They are most abundant in early adult age, and are in 
rather smaller proportions at earlier and later periods. In the foetus, 
however, they exceed the amount in the maternal blood (in the propor- 
tion of 222 to 140, Denis), and this preponderance is retained for some 
weeks after birth, until, in fact, the blood becomes more watery. 

183. Excess of the red pm^tieles might, therefore, be expected to 
cause a general excitement of the vital properties of the body (§ 182). 
Accordingly, Lecanu found that they exist in larger proportion in per- 
sons of sanguine temperament (§ 38), than in others, and especially in 
those of vigorous constitution. Andral and Gavarret detected a slight 
increase of them in some cases of the early stage of infiammations and 
fevers, especially eruptive fevers, as measles and scarlatina. In san- 
guineous plethora, and in hemorrhagic diseases before much blood is 
lost, they were in excess, in some instances rising to 185 in 1000 of 
blood. The obvious sign of the abundance of red particles is the fiorid 
color apparent in the lips, cheeks, gums, and other vascular parts ; the 
deep blue color of the superficial veins ; and the fine deep crimson which 
a thin film of blood gives on a white plate. The bodily functions, ani- 
mal heat, and muscular irritability are in an exalted state, bordering on 
or passing into febrile excitement. Judging by these indications, we 
may often predicate the existence of an excess of red corpuscles in 
those accustomed to good living, with such an amount of exercise in the 
open air as suffices to keep the digestive and assimilative functions in 
an active state. 

^ Annales de CMmie et Physique, Nov. 1840, p. 229. 
2 Ibid. JuiUet, 1842. 



124 ULTIMATE ELEMEN^TS OF DISEASE. 

185. The red particles are defective in persons of the lymphatic or 
leucophlegmatic temperament (§ 40) ; after great losses of blood (artifi- 
cial or from disease) ; in chlorosis, and in other anemic states, as those 
connected with advanced stages of cancer, diabetes, scurvy, and other 
cachectic diseases ; in scrofulous and tuberculous diseases ; in the latter 
periods of fevers, and after severe inflammations ; in granular degene- 
ration of the kidney, and other organic diseases, especially when at- 
tended with dropsy ; in diseases of the spleen, and others of malarious 
origin (§ 85) ; in cases of slow poisoning with lead ; and in persons 
inhabiting dark and ill-ventilated abodes. In an extreme case of chlo- 
rosis, the proportion of the red particles was found by Andral, reduced 
to 27 in 1000 of blood. 

The signs of the defect are, paleness of parts naturally colored with 
blood, pallid or sallow hue of the skin, pink color of superficial veins, 
and a pinkish or light purplish hue of a film of blood on white plate. 
The symptoms of such a condition are those which will be more fully 
described under the head of anaemia ; a weak state of the functions 
generally, of circulation, calorification, digestion, and nutrition, consti- 
tuting their summary. 

[The maximum attained by the red corpuscles in health is 140, whilst 
the minimum is 110 in 1000. Force and strength of constitution are 
the condition of the economy favorable to the former, and feebleness, 
congenital or acquired, to the latter. Sanguine losses, and deprivation 
of food, produce, as a constant effect, diminution in the red corpuscles, 
whilst the fibrine, as we shall see, is less constantly and necessarily in- 
fluenced by these causes. Diminution in the quantity of the red cor- 
puscles may exist as an independent morbid state, or may supervene as 
an epiphenomenon in other diseases. In 24 cases of confirmed spontane- 
ous an?emia, the mean of the red corpuscles was 64 (Andral). In the 
cachectic condition resulting from the poison of lead, so well described 
by Dr. Tanquerel, the red corpuscles fell to the same mean as in spon- 
taneous anj^mia, whilst the other materials of the blood remained 
unaltered. Certain modifications in the organism may influence the 
blood, and diminish the quantity of the red corpuscles. This occurs 
ordinarily in pregnancy. In the neuroses, the blood is remarkably 
poor in red corpuscles ; in phthisis, there is diminution of this constituent, 
as well as in all chronic organic diseases. — C] 

186. Alterations of the red particles are evinced by changes in the 
color of the blood, and in the form of the individual corpuscles, as seen 
by the microscope. The coloring matter is evidently altered in some 
diseases, being much darker than usual, as in the worst forms of scurvy, 
in which the blood is said, by Mead, to be changed to a dark-brown or 
green color ; in the Walcheren and other malignant fevers, it has been 
described as pitchy black. In the worst forms of cachexia (or rather 
cachcemia), from malarious influence, generally in conjunction with 
disease of the spleen, the blood is not only very poor, but perverted, 
exhibiting various shades of purple, brown, and even greenish colors. 
Some change seems to occur in congestive typhoid fevers, in which the 
bloodvessels become stained or dyed of a deep claret color ; this imbibi- 
tion implies a breaking up and unnatural solution of the red particles. 



CHANGES IN THE BLOOD — RED PARTICLES. 125 

Probably the occurrence of petechise and ecchymosed patches in these 
diseases is partly dependent on a similar change. The readiness with 
which the textures become stained in scorbutus, in jaundice, and albu- 
minuria, and in secondary syphilis, seems to indicate an alteration in 
the coloring matter ; inflammations and ecchymoses in the skin being 
commonly followed by livid, purple, or copper-colored stains. The yel- 
low tinge of the skin in yellow fever, occurring chiefly along the course 
of the chief bloodvessels, the peculiar sallowness connected with dis- 
eased spleen and in chlorosis, and the dark discoloration around the eyes 
in the same diseases, apparently proceed from a change in the coloring 
matter of the blood, which causes it to escape from the vessels and tinge 
the skin like in a part discolored by a bruise. The black matter of me- 
lanosis seems to be derived from the coloring part of the blood in an 
altered state ; this is certainly true of the spurious melanosis of the in- 
testines. 

187. Besides changes manifest in the color of the blood, the red 
particles are subject to alterations in their form, size, and other proper- 
ties in connection with the medium in which they are placed. It was 
first observed by Hewson, that pure water causes them to swell, become 
globular, and burst ; whilst saline solutions, containing more salt than 
serum does, make them shrink in size. These changes are now gene- 
rally understood to arise from endosmosis and exosmosis ; the saline 
matter drawing the water into or out of the little cell, which, with its 
contained coloring matter, constitutes the red particle. It is highly pro- 
bable that similar changes may take place in the living body, from cir- 
cumstances which greatly alter the proportion of saline matter and 
water in the blood. May such change contribute to produce the serious 
symptoms, and even sudden death, which have ensued on drinking a 
large quantity of water after great exertion ? Has it aught to do with 
the reaction and irregular excitement sometimes occurring after exces- 
sive losses of blood? Or with the symptoms of sufiiering which animals 
manifest at the instant of injecting water into their veins ? Dr. Owen 
Rees has suggested that the remarkable diminution of the blood-disks 
in cases of albuminuria, may be due to their destruction, in consequence 
of the draining away of albumen from the blood, and thus reducing it 
to a very watery state ; and the same circumstance may prevent their 
redevelopment from the chyle and lymph both in these cases and in 
chlorosis. In several cases of Bright's disease of the kidney, I have 
observed the blood-disks jagged or crenate at their margins, and other- 
wise imperfect ; and the same remark has been made by Simon of Berlin 
and others, and by Andral in a case of chlorosis. [In two cases of 
chlorosis, Andral found the red corpuscles smaller than usual, and many 
of them altered in form, appearing in the field of the microscope as if 
broken into fragments. A young girl whose blood presented this ap- 
pearance, became, after two months of appropriate treatment, plethoric; 
and, at this interval, on the globules being examined, they were found 
in a perfectly healthy state. In an epidemic typhus which prevailed 
in different districts of Italy, in 1841, M. Renzi, of Naples, states, that 
the red corpuscles were readily freed of their coloring matter, seemed to 
have lost their central nucleus, and were altogether less compact and 



126 ULTIMATE ELEMENTS OF DISEASE. 

solid than naturally. In the Edinburgh epidemic fever of 1843, on ex- 
amining the blood of a number of patients, Prof. Allen Thompson and 
Dr. Cormack found the red corpuscles serrated and notched.^ — C] In 
one fearfully rapid example of albuminuria, which proved fatal in six 
days, with effusion of pus in the joints the day before death, I found the 
coloring matter dissolved in the blood-liquor after death, and scarcely 
any red disks remaining. There were numerous pus-globules in the blood. 
A similar total destruction of the blood-disks was observed in University 
College Hospital, in the blood of a person who died of malignant scarlet 
fever with purpura. I have met with similar proofs of breaking up of 
the red particles, but to a much smaller extent, in acute purpura con- 
nected with jaundice, and in cases of disturbed function of the liver 
without jaundice; is this due to the remarkable solvent power exercised 
by small proportions of bile on the red particles, noticed by Simon and 
others ? 

188. The change of the blood from dark to florid, on the addition of 
saline matter, appears to depend on the increased density and distinct- 
ness given to the red particles, and to the colorless globules, whereby 
they reflect light more abundantly, and are also rendered less transpa- 
rent.^ Probably the action of oxygen in reddening venous blood, is of 
a similar character, for it also renders the blood less transparent. This 
explanation of the color of arterial blood was suggested to me by some 
experiments which I made in 1835, and in some measure corresponds 
w^ith the opinion of Dr. Wells,^ that the brighter color is due to fine 
mechanical division. Dr. J. Davy, in 1838, expresses a like conclu- 
sion. More recently, Mulder's notion, that the florid color of the ar- 
terial blood is caused by the formation of a film of solid deutoxide of 
proteine on each particle, implies a similar explanation of the physical 
cause of the bright color, which he farther shows not to depend on any 
change in the coloring matter itself ; but his explanation will not apply 
to the more rapid and complete brightening of blood by saline matter. 
I have noticed that the dark fluid blood found in the body in malignant 
scarlatina, and other bad congestive fevers, does not redden so soon as 
usual on exposure to the air. The same remark applies to some of the 
cases of altered red particles mentioned above (§ 187). 

189. The red particles are distinct structures, living cells, or celli- 
form nuclei (Wharton Jones), although isolated, and floating in a life- 
less fluid. Like other living cells, they probably possess the power of 
secretion ; but what they secrete, whether fibrine or the peculiar princi- 
ples of the excretions, has not been ascertained, and we can, therefore, 
say nothing of their modifications. It has been conjectured that they 
have other vital properties, such as spontaneous motion, and attractions 
and repulsions ; but there are no unequivocal facts in support of such 
notions. The motions described by Treviranus, Schultz, and others, 
may be accounted for on purely physical principles. It is said, that a 
systolic and diastolic movement in blood-particles has been observed, by 
Dr. Martin Barry, in the Fallopian tube of a recently impregnated rab- 

' [Clymer on Fevers, p. 91, Phil., 184G.] 

2 Medical Gazette, Sept. 1835. 3 Pliil. Trans. 1795. 



CHANGES IN THE BLOOD — RED PARTICLES. 127 

bit ; but this seems to have been an effect of the movements of the cilia 
of the membrane. 

190. Hewson, Prevost, Dumas, and others, observed that the red 
particles of new-drawn blood cohere together in piles or rouleaus. This 
cohesion in healthy blood is of very short duration ; for it has been 
remarked by Dr. Hermann Nasse and Mr. Wharton Jones, that in a 
few seconds, the disks may be seen loose and confused ; but in blood 
drawn from a person affected with inflammation, the cohesion takes 
place earlier, is more firm, and lasts longer than usual ; and they con- 
sider this the chief cause of the separation of the red particles from 
the fibrine, which constitutes the buffy coat. We shall notice the rela- 
tion of this phenomenon to the buffy coat under the head of fibrine ; 
but of the cohesion of the red particles, we would remark, that it is not 
certain that it is more than one of mechanical aggregation modified by 
changes in the relative dilution of the liquor sanguinis, without and 
within the blood-corpuscle. The even momentary exposure of so thin 
a film of blood to the air causes evaporation, which affects the serum 
before it can reach the interior of the blood-particles. At this time, 
they cohere ; but the exosmosis proceeding from the individual parti- 
cles, soon again detaches them from each other. ^ But, without dwell- 
ing on this or the equally hypothetical notion that the cohesion is due 
to a vital attraction, it is not unimportant to observe this property, and 
the variety which is presented in inflammatory disease. It has been 
supposed that a similar aggregation of the blood-corpuscles occurs 
within the bloodvessels, and is the cause of obstruction in the capilla- 
ries in inflammation and other cases of impeded circulation. But no 
regular or firm cohesion is seen in the large vessels of a frog's web, 
when the motion of the blood is arrested by pressure on a vein ; and 
although the blood-disks do accumulate and cohere in some of the ves- 
sels of an inflamed part, this will be hereafter shown to be due to an 
obstruction by the colorless particles. (See Inflammation.) 

191. There is still much doubt with regard to the origin of the red 
particles ; and there is a corresponding uncertainty as to the essential 
seat and mode of their increase. It is most probable that their de- 
velopment and growth, as well as their decay, take place throughout 
the sanguineous system, but are most favored by the changes to which 
they are exposed in the great depurative organs, the lungs, liver, and 

^ Hence, as it has been remarked by Mr. Gulliver, the addition of a little salt prevents 
the cohesion of blood-disks. I do not assert that there is nothing vital in these proper- 
ties exhibited by the organized parts of the circulating fluid, but I must protest against 
the hasty assumption made by some physiologists, that the motions and alterations re- 
vealed in animal and vegetable fluids by the microscope, are all dependent on a myste- 
rious vitality. If any microscopical observer will take the trouble to watch the behav- 
ior of any light flaky precipitate recently thrown down from a solution in water or spirit, 
he will see motions and aggregations as remarkable as those of the recently effused blood- 
disks, although less regular from the unequal size and shape of the particles. The close 
and orderly arrangement of the blood-disks is favored by their mobility and flatness, 
which facilitate the operation of the aggregative force ; and in this respect, they con- 
trast with the white globules, whose globular shape and larger mass render them less apt 
to coalesce; they, however, often form centres, around which rolls of disks cluster in cir- 
cles or rays. It is remarked by Mr. Gulliver, that the elliptical particles of reptiles and 
camels cohere together in irregular heaps, without the rouleau arrangement seen in the 
roimd disks, which is therefore the more probably due to their mechanical properties. 



128 ULTIMATE ELEMENTS OF DISEASE. 

Other glands. Whether they originate in the organic globules of the 
chyle and lymph, or from the granules of the white corpuscles, or from 
both, is quite undetermined ; but such an origin appears more in ac- 
cordance with observed facts than their supposed multiplication by the 
division of the old disks. Their increase is intimately connected with 
an active state of the organs concerned in general nutrition, especially 
where their formation is favored by a supply of the ferruginous mate- 
rial which forms a distinctive feature in their composition. 

The influences which promote the decay and retard the formation of 
the red particles (§§ 185, 186), are chiefly those which impair the nutri- 
tion of the body ; but there are some which afi'ect the red particles 
much more than they do other components of the body. Two of the 
most remarkable are a diseased state of the spleen, and disordered 
uterine function. The striking pallidity, or pale sallow hue of persons 
who have been long sufi'ering from malarious influence, more particu- 
larly in warm climates, has often attracted attention; but it is now 
generally considered that these are cases in which the spleen has become 
diseased, an acknowledged result of the continued operation of malaria. 
The state of the blood in these afi'ections has been noticed (§ 186) ; and 
it may be farther explained that a diseased spleen operates not only 
by withdrawing from the circulation an undue proportion of blood, but, 
by keeping it in a stagnant state, unrenewed and unpurified by the pro- 
cesses of circulation and excretion, it sjyoils the blood, and renders it 
unfit for farther use. Hence, when in lapse of time, and under changes 
of circulation when portions of this spoilt blood are again rendered 
into the vessels, they corrupt and contaminate the whole mass, and induce 
the various kinds of cachaemia or cachexia which form the sequels of 
malarious diseases. This view accounts for the fact, often considered 
unintelligible, that such remarkable eff'ects result only from enlargements 
of the spleen, and not from its entire obliteration, which has been re- 
peatedly noticed to occur without any peculiar eff"ect on the blood. 
Other instances of a similar character will be mentioned under the head 
of congestion. 

The mode in which amenorrhcea tends to impair the quality and quan- 
tity of the blood-particles, may also derive some light from the foregoing 
remarks. A young female, during or before menstruation, is exposed 
to continued cold, or sudden mental excitement; the discharge is checked; 
and if no serious illness immediately ensues, she begins to fade, and in 
a few months becomes chlorotic. The uterine system remains congested 
after the repression of the discharge ; and the blood in the system sufl'ers 
not only from the interruption of a process of excretion (M. Gay Lussac 
and Andral have proved it to be such), (§ 170), but also from a reservoir 
of impure blood, which tends gradually to derange and contaminate the 
whole mass. 

192. Remedial Agents. — Excess of the red particles may be speedily 
removed by bloodletting, which reduces these much more than the other 
constituents of the blood. Low or vegetable diet, and the antiphlogistic 
regimen generally, including the avoidance of all stimulating or exciting 
agencies, produce a similar efl'ect more tardily. It is not certain whether 
any medicines directly act in a similar way ; but cholagogue purgatives, 



CHANGES IN THE BLOOD — WHITE CORPUSCLES. 129 

and probably the continued use of mercury, colcbicum, and other medi- 
cines which largely increase the excretions (§ 173), ultimately reduce 
this element. Mineral saline waters, and saline medicines, very co- 
piously taken in a state of much dilution, sometimes reduce extreme 
rubicundity of the surface in so remarkable a degree as to suggest the 
notion that, by their absorption into the mass of blood, they may directly 
destroy some of the red particles ; they are, therefore, useful cooling agents 
where these are in excess. The remarkable pallidity which accompanies 
the occurrence of extensive suppuration, would also point to the formation 
of pus as a means of diminishing the red particles, which means may 
be used artijScially in the form of setons and suppurating counter-irri- 
tants. 

193. To promote the increase of the red particles, where defective^ we 
might expect nourishing food, especially brown meats, exposure to in- 
vigorating air and light, and tonics generally, to be the proper means. 
But without experience, we could not have anticipated that medicines con- 
taining iron should possess such remarkable efficacy in relation to this 
element of disease. In many cases of chlorosis, under the use of any 
suitable preparation of iron, the complexion will change from waxy to 
ruddy, in three or four weeks' time. In the choice of the preparation 
of iron to accomplish this purpose, we must be guided by the state of 
the stomach and other considerations, but where they are borne, the 
most soluble preparations are the most effectual ; and this is of more 
importance than the particular combinations in which they are adminis- 
tered ; thus the iodide, sesquichloride, sulphate, citrate, acetate, and 
phosphate, are all eligible. This subject will again come under our 
consideration in connection with anaemia. 

It has been supposed by Dr. Stevens that saline medicines have great 
power in restoring to their natural condition the red particles which are 
changed in typhoid and malignant fevers (§ 186); but if these remedies 
have any power in such maladies, it is very doubtful how much is to be 
ascribed to this mode of action. A less questionable mode of restoring 
the proper condition of the blood-particles, is by promoting the elimina- 
tion of those diseased, by increasing the excretions (§ 192) ; whilst the 
multiplication of others is aided by the means noticed above (§ 193). 
Thus, in malarious and anaemic cachsemia, the best effects result from 
the combined use of purgatives and diuretics with chalybeate tonics. 
The disposition of the red particles to coalesce, which is augmented in 
inflammation, may be diminished by the addition of saline matter ; and 
Mr. Gulliver has surmised that this may be a part of the useful opera- 
tion of saline medicines in inflammation. 



SECTION YIII. 

FIBRINE AND WHITE COEPUSCLES. 

194. The trifling difference in chemical composition between fibrine 
and albumen (a minute predominance of nitrogen in the first, Dumas), 
9 



130 ULTIMATE ELEMENTS OF DISEASE. 

would scarcely distinguisli them ; but the organizable property of fibrine 
is that which makes the distinction obvious, and most important in phy- 
siology and pathology. Being the constituent which causes the coagu- 
lation of the blood, with all the varieties which that process exhibits ; 
being the part which constitutes the buify coat and coagulable lymph ; 
and being probably the material. by which textures are chiefly nourished 
and repaired, its changes must constitute an important element of dis- 
ease. Although probably not so immediately concerned as the red 
particles in maintaining the vital processes of respiration, circulation, 
and innervation, it is yet a representative of the active state of these 
processes, and of the nutritive and reparative function ; and it therefore 
exists in larger proportion and higher perfection in arterial than in 
venous blood. Although, as above stated, it is distinguished from albu- 
men less by chemical differences than by organizability and suscepti- 
bility of life, yet there are certain conditions, both chemical and physi- 
cal, favorable to the formation of fibrine, through a knowledge of which 
we are able to influence artificially its production. Fibrine, as presented 
to us in the washed clot, coagulable lymph, or the buffy coat of inflamed 
blood, consists of a congeries of extremely fine fibres, with transparent 
granular bodies, separate and in round encysted clusters scattered 
through them. In fluid blood, we see the same encysted clusters or 
pale corpuscles, but none of the fibres. The formation of these fibres 
seems, then, to be the great characteristic of fibrine, and its power to 
assume this form of solid, distinguishes it from albumen, which solidifies 
in a granular mass. So long as fibrine remains dissolved, as in the 
blood liquid, it has nothing to distinguish it from the albumen with 
which it is combined, but it still has the inherent capacity to solidify in 
a peculiar manner. This capacity, from the time of J. Hunter to the 
present, has been generally considered to be an attribute of inherent 
life ; and undoubtedly it is connected with vital activity in the sangui- 
ferous functions ; but various facts, particularly some pointed out by 
Dr. Buchanan, of Glasgow, and Mr. Gulliver, show that the fibrillation 
of fibrine, like the crystallization of a salt, is much promoted by, and 
sometimes dependent on, the presence either of fibrine already solid, of 
the pale corpuscles, or of some kindred solid matter. Exposure to the 
air, and dilution with water, also favor the consolidation of fibrine. The 
former is probably also instrumental in its production ; for the circum- 
stances which promote the formation of fibrine in the blood, generally 
include a certain degree of increased oxygenation. In fact, according 
to Mulder, fibrine is chemically an oxyproteine, or, more definitely, the 
deutoxide of proteine. 

But although fibrine can be thus designated according to its mere 
chemical and physical nature, we must not lose sight of the peculiar 
relation in which it stands to vital properties, which attach themselves to 
it more than to any other constituent of the blood. Its fibres, cells, and 
granules may be regarded as the rudiments of new living textures, and 
in observing its mechanical construction and its chemical constitution of 
deutoxide of proteine, we only note the conditions of a most highly ani- 
malized material, which render it fit for the peculiar properties of life. 

The average proportion of fibrine in the blood of a healthy adult is 



CHANGES IN THE BLOOD — FIBRINE. 131 

about three in a thousand parts. Within the limits of health, it may 
vary from one and a half to four and a half, being more abundant during 
advancing growth in well-fed persons with active circulation ; and less 
so in early infancy, and in persons of weakly constitution and advanced 
age. 

195. An excess of fihrine, and of the colorless globules (hyperplasma, 
or hyperinosis), exists in all true inflammatory diseases, especially those 
of a sthenic character, and those in young subjects, and in acute rheu- 
matism. In some cases, MM. Andral and Gavarret found the proportion 
as high as twelve per thousand. So, likewise, whenever an inflammation 
supervenes in the course of another disease, there is always an augment- 
ation in the quantity of fibrine. The proportion of fibrine is also increased 
during the latter months of pregnancy.^ MM. Andral and Gavarret 
found an increase of fibrine also in tuberculous diseases, in which we have 
noticed there is a deficiency of red particles (§ 185). Mr. Gulliver has 
observed the increase of white globules in blood drawn in inflammation, 
and I have noticed this as occurring within the vessels. (See Inflam- 
mation.) There are other diseases in which blood drawn exhibits a 
fibrinous or buffy coat, as in chlorosis, without there being any absolute 
increase of the fibrine ; this will be noticed presently. It is observed in 
various states of atrophy and cachexia, whether from deficiency of blood 
or defective powers of digestion and assimilation, or excessive expendi- 
ture of the nutrient fluid. 

196. Deficiency of fibrine (hypoplasma, or hypinosis) is of frequent 
occurrence in many diseases, and temporary conditions bordering on 
disease. Its sign is fluidity, or imperfect coagulation of the blood when 
drawn. As venous blood contains less fibrine and of a less perfect qual- 
ity than arterial, so the quantity is absolutely diminished when the 
blood is more venous than usual, as in cases of asphyxia or impeded 
breathing ; and in those of cyanosis, in which the venous blood becomes 
mixed with the arterial through an unnatural opening. Excessive 
bodily fatigue more or less expends the fibrine ; hence the blood often 
remains fluid in animals hunted to death (§ 65). It w^as stated by 
John Hunter that the same thing is observed in animals killed by 
lightning, but this is not generally the case. In many instances, 
the blood is found fluid in cases of death from poisoning and other 
sudden causes. In some of these, the absence of fibrine may be 
attributed to the impeded respiration, which is the immediate cause of 
death, as in some cases of death from hydrocyanic acid, opium, strych- 
nia, apoplexy, dividing the pneumogastrics (Dupuy), &c. There is, 
however, some uncertainty about these facts. (See Mr. Blake's experi- 
ments, mentioned farther on.) But in others, as in poisoning with arse- 
nic, sulphuretted hydrogen, and some other pernicious agents, the fluid 
state of the blood must be ascribed to a more direct operation on the 
blood itself. So likewise in adynamic fevers, which arise from a pecu- 
liar poison, the fluidity or imperfect coagulation of the blood is one of 
the most remarkable conditions, and seems to be a chief cause of the 

' In domestic animals, the fibrine is diminished before, and increased after, parturition. 
(Ann. deChim. 1842.) 



132 ULTIMATE ELEMENTS OF DISEASE. 

hemorrhages, petechise, and vihiees, which sometimes occur in these 
fevers. In a case of very low typhoid fever, Andral found the propor- 
tion below one in one thousand. The artificial imitations of these fevers 
produced in dogs inoculated with various morbid or putrid matters, or 
confined over their exhalations, in the experiments of Gaspard, Magen- 
die, Gendrin, Leuret, and Hamon, exhibited a similar absence of fibrine 
in the blood (§ 194). This absence of fibrine was observed by Scherer, 
in one case of putrid fever, to be accompanied by the presence of car- 
bonate of ammonia, doubtless from incipient putrefaction. 

The addition of some neutral and alkaline salts to the blood out of 
the body will diminish its coagulating property ; and it has been stated 
that subsisting on salted food will produce a dissolved or hypoplastic 
state of the blood during life ; but this statement does not appear to be 
founded on any. well-ascertained facts, and is perhaps connected with 
the notions that salt food is the cause of sea scurvy (§ 63), and that the 
blood does not coagulate in this disease, both of which are erroneous. 
(See Lib. ofPract. Med., Art. Scurvy, by Dr. G. Budd.) 

197. Besides the sign already mentioned, permanent fluidity, or little 
coagulation of the blood when drawn, a defect of fibrine causes a tend- 
ency to hemorrhages, generally of the asthenic kind, and to an un- 
manageable oozing of blood from any accidental wound or breach of tex- 
ture. In the same cases, too, wounds do not readily heal, nor fractures 
unite. In fact, the plastic or reparative process is defective for want of 
its material (§ 194) ; and for a similar reason, the nutrition of textures 
which consist chiefly of fibrine, such as muscle, is ill maintained. 

198. Magendie found that animals, from whose blood fibrine had been 
abstracted, were affected with congestions and effusions in the lungs, 
brain, and other organs, which he ascribes to a cause supposed by M. 
Poisseuille to be a general physical fact ; that very thin fluids pass with 
greater difiiculty through capillary tubes than those of somewhat greater 
spissitude. But his experiments were too rude and his deductions too 
hasty to merit confidence ; and the obstructions and congestions alluded 
to might be equally due to the cohesion of colorless or blood particles, or 
even to little clots of fibrine left by the coarse process employed. There 
can, however, be no doubt that a certain spissitude in the blood is favor- 
able to its transit through the hydraulic apparatus of the circulation ; and 
that when this is deficient, various irregularities in the distribution of 
the blood may occur. Some of these will be mentioned under the head 
of anxmia ; but I may mention here that thin blood is easily thrown 
into sonorous vibration, and various unnatural sounds or murmurs in 
the heart, arteries, and veins, may be thus produced. As these are 
sometimes met with in cases in which the complexion does not indicate 
a deficiency of red particles, and they are sometimes absent in the mosc 
pallid subjects, I am inclined to connect them as much with defect of 
the fibrine and albumen as with that of the red particles of the blood. ^ 

199. Alterations in the quality of the fibrine introduce to our notice 

1 This inference has been confirmed by the subsequent observations of MM. Becquerel 
and Kodier, wlio found tliat in the pallid cachexia from the poison of lead, in which the 
albumen is not diminished, the vascular murmurs are not present. 



CHANGES IN THE BLOOD — FIBRINE. 133 

the important morbid appearances presented by the buiFy coat and con- 
traction of the clot of blood. 

As the consolidation of the fibrine is the cause of the coagulation of 
the blood, so diiferences in the coagulum represent variations in the 
proportions and properties of the fibrine. 

200. A large firm coagulum indicates an abundance of fibrine, as well 
as of red particles, and is commonly presented by healthy blood. A 
loose coagulum implies a deficiency of fibrine. A small firm clot be- 
tokens a proportion of fibrine exceeding that of the red particles ; but 
the smallness of the clot points to another property of the fibrine, which 
is in excess, that of contraction during and after its consolidation. Again, 
in this case as in others, the upper part of the clot is commonly more 
contracted than the lower portion ; it is also firmer, and contains more 
fibrine, whilst the lower abounds more in red particles. Here there is 
evidently a tendency to a separation of the red particles from the fibrine. 
In other cases, again, the separation is to some extent complete, the red 
particles subsiding, whilst the fibrine rises to the surface, and, on co- 
agulating, forms at the top of the clot a layer of a light yellow or bufi" 
color, commonly known by the name of the huffy coat. 

201. It may be inferred, then, that besides coagulation (§ 194), fibrine 
possesses a property of contraction^ and another of separation from the 
red particles ; and these properties are presented in different degrees in 
different^ states of the system. Let us consider these properties, first 
separately, afterwards in combination. 

202. Coagulation is generally retarded in inflamma^tory diseases, and 
in other cases in which the fibrine is abundant (§ 195) ; its amount is 
indicated by the firmness and size of the clot. Other circumstances, 
however, may make the coagulation slow, as warmth and seclusion from 
the air ; whereas cooling quickly, and exposure to the air, as when the 
blood trickles from the vein, or is drawn into a shallow vessel, hasten 
the coagulation. The addition of some saline matters, such as common 
salt, carbonate or sulphate of soda, also retards the coagulation of the 
blood. 

203. The contraction of the clot evidently depends on the attraction 
of the particles of fibrine for one another after the coagulation has be- 
gun. By the contraction, the red particles entangled in the fibrine are 
also drawn together whilst a portion of the serum is squeezed out. The 
more slow the coagulation is, generally, the greater will be the contrac- 
tion. Hence the upper surface of the clot is often formed more quickly 
(§ 202), and is therefore larger than that below, whilst the middle por- 
tions of this large upper film being drawn downwards by the contraction 
of that below, cause the concave or cupped appearance in the clot, so 
commonly seen in buffed blood (§ 200). By drawing blood sloAvly, or 
in a shallow vessel, the coagulum is speedily formed in all parts, and ad- 
hering to the sides it is not cupped (§ 202). The contraction and cup- 
ping of the clot being due to the fibrine, might be expected to be in 
proportion to its quantity ; and this is the case in inflammatory diseases. 
But there is also great contraction and often cupping in chlorosis and 
some analogous states, in which the fibrine is not absolutely increased ; 
the red particles being much diminished, the contractile property of the 



134 ULTIMATE ELEMENTS OF DISEASE. 

fibrine is not impeded. For a similar reason tlie contraction is greatest 
where the quantity of fibrine is greatest, and most completely separated 
from the red particles. On the other hand, there is little or no con- 
traction where the red particles are in proportionate abundance, as in 
sanguineous plethora (§ 184), or where the aggregation of the fibrine is 
impaired by the addition of saline matter (§ 196). In a boy under my 
care with purpura. Dr. Garrod found the fibrine in the blood quite as 
abundant as usual, amounting to 3 in 1000 parts, but it was remarkably 
defective in the usual contractile property ; and the salts of the blood 
were in excess. 

204. The separation of the fibrine from the red particles (§ 200), as 
exhibited in the buffy coat, has attracted much attention, and has been 
ascribed to various causes. As the fibrine ahvays rises to the surface, 
and the red particles sink, it is obvious that a chief cause of the separa- 
tion is the greater weight of the latter, which subside entirely from the 
upper layer of fibrine before it has time to coagulate. Now, this separa- 
tion may be favored by four circumstances : 1, the tardy coagulation of 
the fibrine giving more time for the separation ; 2, increased specific 
gravity of the red particles ; 3, diminished specific gravity of the 
fibrine ; 4, diminished spissitude of the liquor sanguinis. Now, two of 
these conditions may be fulfilled by adding a little salt to healthy blood 
as it flows from the vein ; and this addition really does produce a 
separation of the fibrine ; but the fibrine thus rising to the surface has 
neither the contraction (§ 203) nor the firmness of the inflammatory 
bufi", but is gelatinous, like size, and rather resembles the sizy blood 
sometimes exhibited in scurvy and diabetes. Farther, although blood 
in inflammation is generally slow to coagulate, it is not so always ; and 
in extreme cases, as in acute rheumatism, the buff appears even where 
the coagulation is speedy, and, according to Schroeder Van der Kolk, 
is seen in patches and thin films where gravitation would not have pro- 
moted the separation.^ There must, then, be some other cause for the 
formation of the buffy coat besides those above mentioned. The great 
firmness and contraction of the surface of inflamed blood maybe ascribed 
to the increased proportion of fibrine, which is constantly present. 

[Whenever there is excess of fibrine, whether relative or absolute, and 
the coagulation of the fibrine does not occur too rapidly, it will accumu- 
late alone on the surface of the clot, and form a buffy coat. Thus the 
blood of anemia is buffed, whilst that of plethora is not ; the buff in the 
blood of pregnant women is owing to the excess of fibrine relatively to 
the globules. This explains, too, the buff in the blood drawn from horses, 
where there is predominance of fibrine over the red corpuscles. — C] 

205. Dr. Alison considers the separation of the fibrine in inflamma- 
tion to be due to a vital repulsion between the fibrine and the coloring 
matter. Dr. Hermann Nasse and Mr. Wharton Jones think that the 
tendency to separate may be entirely explained by the increased aggre- 
gation (before noticed, § 190), which they observed in the red particles 
of inflammatory blood (Brit, and For. Med. Rev. Oct. 1842, p. 592). 
This cohesion of the red corpuscles in separate piles, or rouleaux, would 

' Alison's Outlines of Pliysiology, p. 80. 



CHANGES IX THE BLOOD — FIBRINE 



135 




facilitate the separation, not only by contractile aggregation, but also 
by sinking through the liquid fibrine more quickly than separate parti- 
cles would; just as bits of chalk fall to the bottom of water instead of 
remaining long suspended, as they would do in fine powder. Accord- 
ingly, Mr. Gulliver has observed that the red particles sink rapidly in 
proportion to this aggregation. But another circumstance favoring the 
separation of the bufiy coat, is its own increased lightness, due appa- 
rently to an increased proportion of fat-globules contained chiefly in 
the pale corpuscles diffused through it. 

The subjoined sections of the different appearances of coagulated 
blood may assist the student to understand their nature and causes. 

206. This presents uniform coagulation with 

little contraction. If the clot be moderately firm, Fig- 1- 

the blood is rich in fibrine and in red particles, as 

in that from persons in robust health. If the clot 

be very soft and uniform, the fibrine is deficient, 

as in typhoid fevers, exhaustion from fatigue, 

&c. If the clot be very soft, especially at the 

bottom, and the top covered with a soft, sizy 

film, the coagulation has been slow, as in scurvy 

and in slight inflammations occurring in typhoid 

fevers. 

207. This diagram exhibits uniform coagula- 
tion with great contraction, which takes place 
where the proportion of fibrine much predomi- 
nates over that of the red particles, as in chlo- 
rosis. The relative as well as the absolute quan- 
tity of the fibrine is indicated by the firmness of 
the clot. This appearance, with a buffy surface, 
is often exhibited by blood drawn in inflammation 
in ansemic subjects or in advanced stages, and in 
phthisis. 

208. Blood highly buffed and cupped, as in 
acute rheumatism and other severe inflammations. 
The fibrine here presents in a high degree its 
properties of separation, coagulation, and con- 
traction ; having abandoned the red particles, 
which are loose at the bottom of the vessel, and 
having risen to the surface, where it appears as 
concave, and buffy clot. 

209. To exhibit the true properties of the blood in coagulation, it 
should be drawn by a full stream into a deep or globe-shaped basin or 
cup, previously warmed, and kept covered over until the coagulation is 
complete. These precautions retard the coagulation, and favor the 
separation and contraction of the fibrine. On the other hand, if the 
blood merely trickles from the vein, as when the orifice is small or the 
patient faint, or when the receiving vessel is shallow and cold, the blood 
congeals at once, and prevents the appearance of the buffy coat (202). 




Fio;. 3. 




tough. 



contracted. 



136 ULTIMATE ELEMENTS OF DISEASE. 

This is one reason why blood drawn at one bloodletting often exhibits 
a different appearance in different vessels.-^ 

210. We have before noticed that the fibrine of the blood may be 
speedily exhausted by violent muscular exertion, and by serious impedi- 
ment to the respiration (§ 196). These, and the fact that it exists in 
larger proportion in arterial than in venous blood, seem to point out 
that it is expended in the nourishment of the muscular and other tex- 
tures, and is renewed through the agency of respiration. It might be 
supposed that inflammation increases its quantity by accelerating the 
circulation and respiration without adequate expenditure ; but. although 
this may be a contributing cause, particularly in acute rheumatism, it 
is not sufficient, for the quantity of fibrine is not proportioned to the 
frequency of the pulse or respiration ; it is often much increased before 
these are materially affected, and in idiopathic fevers it is diminished, 
although the breathing and pulse are commonly accelerated. In fact, 
various circumstances, to be detailed hereafter, render it probable that 
the increase of fibrine during inflammation has its origin in the vessels 
of the inflamed part. 

211. It has been before stated (§ 194), that the coagulation of fibrine 
in the blood is favored by two circumstances, the presence of the pale 
corpuscles, or of their constituent granules, and the formation of the 
deutoxide of proteine by some oxygenating process operating on the 
albumen ; the same circumstances appear to be mainly instrumental in 
its formation. Thus, as Dr. Carpenter has pointed out, the fibrine ap- 
pears in the chyle of the lacteals after their passage through the mesen- 
teric glands ; it increases in the thoracic duct, and becomes still more 
abundant in the blood in the lungs where there is a free supply of 
oxygen. It is quite uncertain how much in this process is due to vital 
influence, but there is good ground for belief that much of the change 
is of a chemical nature. The moleeidar base of the chyle (Gulliver) 
supplies a congeries of minute fat-globules which have a tendency to 
attract around them thin films of coagulated albumen (Ascherson), pro- 
bably identical with fibrine or deutoxide of pi^oteine ; and this process 
takes place in proportion as oxygen is supplied from the adjoining red 
blood-disks ; thus the molecular base is converted into single and aggre- 
gated granules or i^ale corpuscles of the chyle and blood. The oxy- 
genating process extends farther, and converts a small portion of albu- 
men into an oxyproteine, still liquid, but ready to take the form of a 
finely fibrillated solid (fibrine), under various circumstances before ad- 
verted to (§ 191) ; and the perfection of this material, and its suscepti- 
bility of the process of farther organization, form additional characters 
of fibrine, which appears to belong to the class of vital rather than mere 
physical properties. These will be noticed in the next paragraph ; but 
we may observe here that they will much depend on the quality of the 
chemical materials, oil and proteine, which the chyle and blood contain, 
and the activity of the processes of circulation and respiration, which 
are continually acting on these fluids. 

1 For much interesting information on the coagulation of the blood, the reader is re- 
ferred to the edition of Hewson's works, published by the Sydenham Society in 184G, with 
the valuable notes of Mr. Gulliver. 



CHANGES IN THE BLOOD — FIBRINE. 137 

212. Fibrine, or the bufFy coat of the blood, is the material of which new 
membranes and cicatrices are formed, constituting the coagulahle lymioh, 
which is the plasma or basis of the constructive or reparative process. 
In its capacity for this process, fibrine exhibits some varieties. The 
plasma with which old textures are nourished, and new ones formed, is 
euplastic in a healthy state, having a capacity of life, and may become 
organized in a high degree, as in the case of false membranes resulting 
from acute inflammation in a healthy subject. But in many instances, 
this capacity is degraded, and the nutritive material is caco-plastic, 
susceptible of only a low degree of organization, as in the indurations 
resulting from low or chronic inflammation, in fibro-cartilage, cirrhosis, 
gray tubercle, kc. ; or it is aplastic, not organizable at all, as in pus, 
curdy matter, yellow tubercle, &c. It is a fact of great importance, 
that the quantity of fibrine in the blood, and the facility with which it 
may be effused, are by no means in proportion to its plasticity, or capa- 
city to become organized ; thus it is abundant in the blood, and freely 
effused in the inflammations of scrofulous or tuberculous subjects, al- 
though in such the products of these inflammations and of nutrition are 
commonly caco-plastic or aplastic. The fibrine of the blood or coagu- 
lahle lymph in these cases, is more opaque and less elastic than in 
healthy subjects, and under the microscope, presents a predominance of 
granular matter and fat-globules, and less of the finely defined fibres 
and regular nuclei, as if it were imperfectly elaborated, and resembled 
coagulated albumen rather than the more animalized form of proteine. 
Even the more perfect forms of fibrine, if in a position in which their 
vitality is not sustained by becoming organized, tend to degenerate and 
become disintegrated into an opaque aplastic matter (Gulliver), and this 
eventually may undergo a farther chemical change into fatty and calca- 
reous matter, like other aplastic deposits. It is interesting to observe 
that in these cases, also, the red particles are defective in number 
{§ 185) ; and this suggests a probable cause of the imperfection of the 
plasma. 

213. The coagulation of fibrine is promoted by the contact and motion 
of a rough solid ; thus by stirring fresh-drawn blood with a stick, the 
fibrine adheres in shreds to the stick. The same property is exhibited 
within the body in the deposition of lymph (vegetations) on rough sur- 
faces within the heart and great vessels, and it is probable that the 
fibrinous concretions called polypi, which are found after death in the 
heart, are formed on its irregular surfaces, as its failing motions cause 
agitation more than propulsion of the blood. The cohesive property of 
fibrine especially characterizes it, and causes it to aggregate in patches 
and films on the surface of membranes ; and where it is most plastic, it 
may be drawn into threads or bands. 

Remedial Agents. 

214. Hyperinosis, or excess of fibrine (§ 195), is less reduced by blood- 
letting and low diet, than is excess of the red particles; yet these are the 
chief means of effecting this object. It would probably be found that 
purgatives, and other remedies which increase much the more solid secre- 
tions, diminish the fibrine. A similar property has been ascribed to mer- 



138 ULTIMATE ELEMENTS OF DISEASE. 

cmy, to alkaline salts, to iodine, and to antimony ; there is a want of 
experimental proof in support of this notion ; yet it is favored by some 
analogies, and seems well worthy of fuller investigation.^ The operation 
of salts and alkalies in this way was probably suggested by their pro- 
perty of dissolving fibrine out of the body.^ 

215. According to the views of Dumas and Liebig, subsisting chiefly 
on saccharine, amylaceous, or gelatinous articles of food, must reduce 
the fibrine and albumen of the blood ; and such food is found by expe- 
rience to be the best in inflammatory diseases, in which excess of fibrine 
is a chief element. Is the reputed efiicacy of the " cure de raisins," in 
tuberculous disease, connected with the absence of proteine compounds 
in the food ? Bodily exercise reduces the fibrine, and may be advanta- 
geously employed with this view in sthenic plethora and in scrofulous 
hyperinosis ; but is not admissible in inflammatory diseases. Neither 
can we suggest any practicable mode of lessening the fibrine by lowering 
the function of respiration, on which its supply seems to depend, unless 
narcotics, which impair many organic functions, have some action of 
this kind. The known utility of opium, aconite, &c., in rheumatism 
and low forms of inflammation, in which excess of fibrine is a constant 
element, makes this matter deserving of some research. Simon men- 
tions one case of phthisis long treated with cod-liver oil, in which the 
fibrine in the blood was reduced in a remarkable degree.^ 

216. Hypoplasma, liyponosis, or deficiency of fibrine (§ 196), is to be 
remedied by assisting those functions on which its supply depends, par- 
ticularly those of digestion, circulation, respiration, and assimilation, and 
by avoiding its expenditure by too much exercise, and other exhausting 
processes. If the digestive organs will bear them, meat, eggs, bread, 
and other articles of diet abounding in the proteine compounds, should 
be taken. The digestive and assimilative functions may be assisted by 
stimulants, bitters, quinia, and the mineral acids, which, from their 

1 Dr. Karl Popp, in Ms elaborate researches on the composition of the blood, infers 
that tartar emetic and nitre, and in a less degree calomel, diminish the amount of fibrine. — 
Dr. Day, in Ranking^ s Abstract, June, 1846. 

2 Mr. James Blake* has made many experiments by injecting various saline and other 
fluids into the veins, and he has furnished me with a summary of their effects on the 
blood, as found after death. 

The blood was found coagulated after the injection of the following matters : Liquor 
potass93 (firmly); carbonate of potass (firmly); nitrate of potass (firmly; blood scarlet) ; 
nitrate of soda ; nitrate of ammonia ; nitrate of lime ; nitrate of baryta ; chloride of 
calcium ; chloride of bai-ium ; chloride of strontium ; sulphate of magnesia ; sulphate of 
copper; acetate of lead; arsenite of potass; nitric acid (strongly) ; narcotine (firmly); 
tobacco ; strychnia (moderately) ; conium ; hydrocyanic acid ; euphorbium ; and water 
in quantity. 

The blood was not coagulated, or imperfectly so, after injection of caustic soda, car- 
bonate of soda, sulphate of soda, ammonia, nitrate of silver, sulphate of zinc, sulphate 
of iron, phosphoric acid, arsenic acid, arsenious acid, oxalic acid, infusion of galls, of 
digitalis, alloxan. 

Some of tliese results are different from what might have been expected ; instance the 
decided coagulation with potass and its salts, especially nitre, and the fluidity with ni- 
trate of silver, sulphate of zinc, infusion of nutgalls, Avhichhave been commonly supposed 
to possess a coagulating property. 

3 [Animal Cliemistry, by Day, p. 230, Am. Ed.] 



* [The present Professor of Anatomy in the St. Louis University, Missouri.] 



CHANGES IN THE BLOOD — FIBRINE. 139 

power in stopping passive hemorrhage, in augmenting the muscular 
substance and strength, and in causing the healing of phagedenic and 
flabby ulcers, seem to promote the formation of fibrine more directly 
than by their mere operation on the digestive organs. To improve the 
function of respiration, besides attempts to remove or diminish any dis- 
ease from which it may suffer, the free access of pure cool air to the 
lungs should be secured. The injurious effect of exertion is exemplified 
in the relapses which it often induces in continued fever, in which, de- 
fect of fibrine in the blood is a chief element. Fatigue of every kind, 
and wakefulness, should be carefully avoided, and sleep obtained by 
narcotics, if it do not come naturally. In case of deficiency of fibrine 
from the presence of a febriferous or putrescent poison in the system, 
it is not to be expected that fibrinous food, rest, or any other means, 
can remove the deficiency, so long as the poison remains in active opera- 
tion. This poison, by its septic or analogous influence, interferes with 
the vital process by which the fibrine is formed. But no sooner does 
the influence of the poison subside, as evidenced by improvement in the 
symptoms, than the quantity of fibrine increases ; and this sooner than 
could be explained by any increase of nourishment taken (Andral and 
Gavarret). 

217. Very little is known of the power of remedies to correct changes 
in the quality of the fibrine of the blood. The increased properties of 
separation (§ 204) and contraction (§ 203) manifested by blood in in- 
flammation, are reduced by bloodletting and other antiphlogistic reme- 
dies, even more constantly than the excessive proportion of fibrine is by 
the same means ; but they seem to be soon reproduced if the inflamma- 
tion continues. Thus, although the last cup drawn in bloodletting may 
exhibit none of the buffed and cupped appearance presented by the first 
cups, yet blood drawn a few hours after, often shows as much as any 
taken before. Knowing that this speedy recurrence of morbid proper- 
ties in the blood depends on the influence of the local inflammation, we 
see the necessity of fully using local means, together with those calcu- 
lated to operate on the system. 

The beneficial influence of saline medicines in inflammatory diseases, 
is supposed by Mr. Gulliver to depend on their power to prevent the co- 
hesion of the blood-particles, and he suggests the free application of salt 
lotions to an inflamed part. The application of salt to a recent wound, 
is a well-known popular remedy. 

218. Bloodletting and other general antiphlogistic remedies, if they 
do not remove local inflammation, may render its products more injuri- 
ous by lowering their plasticity (§ 211), and approximating them to 
tuberculous and other aplastic deposits. Thus, chronic inflammation 
continuing after the full application of the antiphlogistic treatment, 
almost surely tends to pr6duce degenerated changes of structure, over 
which remedial art has little power. In connection with this subject, 
therefore, we see how desirable it is that inflammations should be removed 
before they become chronic ; and when there is a risk of their becoming 
so, it should be an indication to improve the condition of the blood 
by a tonic and nutritive plan, at the same time that local antiphlogistic 
measures may be necessary for the lingering inflammation. 



140 ULTIMATE ELEMENTS OF DISEASE. 

219. A. similar tonic treatment is still more indicated in scrofulous, 
chlorotic, and other cachectic states, in which the fibrine, although less 
abundant than in inflammation, is yet copious in proportion to the 
scanty red particles (§ 212). Hence the tendency to the deposit- of im- 
perfect fibrine and granular matter (§ 211), even independently of in- 
flammation; and besides means calculated to improve the nutrient func- 
tions, and to raise the character of their product, it may be necessary 
to use remedies likely to keep the fibrine dissolved, and to prevent its 
deposit in its aplastic forms. Alkalies and iodide of potassium have 
been supposed to have some claims to these properties ; but more effi- 
cacy seems to attach to regiminal and dietetic means, which, excluding 
all food containing solid fat, and proteine matters of the lower class 
(such as caseine), secure the freshest and most nutrient food, and pro- 
mote the digestion, respiration, capillary circulation and excretion, by 
healthy air, exercise, frictions, and suitable medicines. 



SECTION IX. 

ALBUMEN AND OTHER ANIMAL PRINCIPLES DISSOLVED IN 

THE SERUM. 

220. These form a considerable constituent of the blood, amounting 
on an average to between seventy-six and eighty per thousand in health. 
It is generally supposed that the albumen of the serum is chiefly useful 
as affording the material from which the plasma (fibrine) is elaborated; 
but it is by no means certain that some textures, such as those less high- 
ly organized, composed of albumen and gelatine, may not be formed at 
once from the constituents of the serum. The albumen is farther use- 
ful in giving to the serum a consistency favorable for its circulation, for 
suspending and preserving the red corpuscles, and in blandly sheathing 
the acrimony of the saline constituents. The quantity of albumen is 
estimated by Andral and Gavarret at from 7 to 8 per cent. It may 
be generally inferred from the specific gravity of the serum, which in 
healthy subjects averages at about 1030. 

221. Excess of Albumen exists in most cases of inflammations and 
fevers, especially during their more active stages. Its increase is not, 
however, in proportion to that of the fibrine. Its relative proportion is 
much increased in epidemic cholera; but this is rather due to the removal 
of the water of the blood. Albumen is the principle least affected in 
its proportions by disease. Very poor living, long-continaed extensive 
hemorrhages, and other drains on the system* will pretty surely reduce 
it in common with the other animal principles of the blood ; but good 
living has less power in raising it above the natural standard. In the 
pallid cachsemia of persons long suffering under paraplegia, it has been 
ascertained by ^IM. Becquercl and Rodier, that the albumen is not 
diminished, and is therefore, in excess, as compared with the other solid 
constituents of the blood. 



CHANGES IN THE BLOOD — ALBUMEN; OIL. 141 

222. Deficiency of Albumen in the blood is most remarkably met with 
in cases of albuminuria, or disease of the kidney with coagulable urine ; 
and this deficiency precedes the diminution of the red particles, which 
takes place in the advanced stages of this disease. Dr. Bright found, in 
a patient with albuminuria, the specific gravity of the serum as low as 
1013. [BrigMs Reports^ vol. i. p. 85.) Dr. Babington found the 
specific gravity of the serum in a case of diabetes as low as 1024 ; in 
another 1027, although that of the blood was higher than usual, 1061. 
In this case the serum was milky. [Cycl. of Anat. &c. Art. "Blood.") 
In their latter researches, MM. Andral, Gavarret, and Delafond, dis- 
covered a remarkable diminution of the albumen in dropsical sheep 
affected with the rot (a watery state of the blood, with distomata in the 
liver). Sheep in a cachectic state, with deficiency of red particles, but 
without entozoa, were not dropsical, and in these, the albumen was 
found undiminished. It is therefore most probable that the cases of 
cachexia, or anaemia, attended by dropsy, owe this concomitant to a 
defect of albumen in the blood. It is this principle chiefly that gives 
the blood liquor its spissitude, which renders it more fit to pass along 
the vessels, and prevents it from transuding through their walls. This 
deficiency of albumen, therefore, seems to be a chief constituent of the 
dropsical diathesis. 

We are not acquainted with any means of increasing albumen in the 
blood where it is deficient, farther than those which restrain wasting dis- 
charges, and improve general nutrition. A case is mentioned by Simon 
(Animal Chemistry^ by Day [p. 230, Am. Ed.]), illustrative of the 
extraordinary nutritive properties of cod-liver oil in phthisis ; the solid 
constituents amounted to 25 per cent., the albumen being above 1-3 ; 
whilst the fibrine, which is usually high in phthisis, was reduced below 
the normal proportion. 



SECTION X. 

OIL. 

223. The oil or fatty matter in the blood sometimes is so much in- 
creased as to give a milky appearance to the serum ; and this increase 
may arise under diff'erent circumstances, and^ from various causes. The 
most common is that originally suggested by Haller, and lately proved 
by Dr. Buchanan, that it depends on the presence of unassimilated chyle 
(§ 211). The latter physician has ascertained that the serum is gene- 
rally milky in blood drawn four or five hours after a full meal. In other 
instances, this appearance has been observed during illness after long 
fasting, and doubtless proceeds from the absorption of fat from the tex- 
tures, as supposed by Hewson. In some cases, a turbidity in the serum 
has been found to depend on an increased number of minute granules of 
albumen or fibrine, soluble in acetic acid, and not affected by ether. 
(Vogel's Path, Anat, by Dr. Day [p. 48, Am. Ed.]. Notes to Hetvson's 
Works, by Gulliver, p. «5.) Dr. Babington met with an extreme degree 



142 ULTIMATE ELEMENTS OF DISEASE. 

of milky serum in a case of advanced diabetes. This physician states 
that he has repeatedly found milky serum to have a low specific gravity, 
indicating a deficiency of albumen ; and he suggests that the fat might 
originate in a change in the albumen. A similar idea has frequently 
occurred to me, when considering the remarkable instances of fatty 
transformation exhibited in degenerating textures and deposits, and even 
in slowly decaying animal matter, as in the instance of the production 
of adipocire. I shall revert to this subject under the head of Trans- 
formations and Degenerations. The fat of the blood seems to vary in 
its nature ; cholesterine and margarine are often found in old and 
cachectic persons, and often abound in the degenerated tissues and 
cacoplastic deposits of such subjects. 

224. The increase of fat in the textures is probably preceded and 
accompanied by its presence in excess in the blood ; and the circum- 
stances which promote obesity must operate through the composition of 
this fluid. Of these may be mentioned fat, sweet and farinaceous food 
in excess, yet without causing disorder of the digestive organs ; full liv- 
ing with sedentary habits, and especially combined with the free use of 
malt liquors; imperfect assimilation, often connected with imperfect ex- 
ercise of the respiratory organs, from disease or disuse ; insufficient ex- 
cretion of bile. Exercise tends especially to reduce the fat of the body, 
probably by causing its combustion in respiration, whilst the nutrition of 
muscular textures is increased by the same influence. Thus, unhealthy 
fat commonly increases at the expense of strength, and is reduced in 
proportion as muscular power is restored. In addition to the use of as 
much exercise as the strength will bear, and the invigorating influence 
of pure air, and the avoidance of all fat and other articles of food 
abounding in hydrocarbon, some advantage may be derived from the 
employment of food and medicines in which oxygen and azote pre- 
dominate, such as nitric acid, benzoate of ammonia, and some vegetable 
acids. 

Defect of fat in the blood has not, to my knowledge, been observed: 
but it may be presumed to occur in cases of inanition and emaciation 
of long standing, particularly in those of advanced stages of malignant 
disease and tabes mesenterica. This element of disease, and the still 
more important one of alteration in condition of the fat-globules which 
fof-m the basis of nutrition, will be better considered under the head of 
diseased nutrition, when the remarkable powers of the cod-liver oil as u 
remed}^, will demand our attention. 



SECTION XL 

SALINE MATTER 



225. The saline matter dissolved in the blood tends to preserve the 
form of the red particles, and the fluidity of the fibrine. A^ogel states 
that it is in excess in scurvy, and causes the hemorrhagic disposition in 
that disease: but this does not accord with what has been observed in 



CHANGES IN THE BLOOD — SALINE MATTER; WATER. 143 

this country (§ 196). He also thinks that the same cause renders the 
red corpuscles granular or puckered at their margin by withdrawing 
some of their fluid contents. Such an appearance^of the red particles, 
as well as an excess of saline matter, exists in the blood of a boy with 
purpura, now under my care. 

There can be little doubt that the thirst induced by salt food is con- 
nected with an excess of saline matter in the blood, which causes a 
shrinking in size of the red corpuscles; and wherever they circulate, 
they attract by endosmose fluid from the textures and surfaces, exciting 
that demand for liquid which the feeling of thirst is intended to supply. 

226. Diminution of saline matter in the blood has been said, by Dr. 
Stevens, to take place in yellow fever and other pestilential diseases, and 
to cause so dark and grumous a state of the blood, that exposure to air 
will not, as usual, render it florid. This fact has been more distinctly 
ascertained by Dr. O'Shaughnessy, with regard to malignant cholera, in 
which the defect of saline matter "and water seems to be the immediate 
cause of the obstructed circulation, lividity, and collapse, so remarkable 
in that terrible disease. Accordingly, Dr. Mackintosh found the blood 
extensively coagulated in the heart and large vessels. There can be 
no doubt, therefore, that in the extreme cases just mentioned, the blood 
coagulates in the vessels for want of saline matter, and the red particles 
become dissolved and altered. 

227. Hence the temporary efficacy of injection of saline solutions into 
the veins of cholera patients; it seems at once to renew circulation, 
respiration, warmth, and other functions — life, in fact, to the patient — 
as if the saline solution were all the thing needed. But this defect of 
serum in the blood is only an effect of the excessive evacuations from 
the stomach and bowels ; and if these go on, the good effect of saline 
injections is soon- exhausted. 

The researches of Andral scarcely support the notion that similar 
changes take place in typhus fever, as supposed by Dr. Stevens. If 
saline medicines are useful in common continued fevers, it is a question 
whether it is in this way, by supplying what is defective ; it may rather 
be by augmenting deficient secretions (§ 171), and tending to remove or 
counteract septic influences present in the system (§§ 98, 105). 

It is stated by Henle that a diminution of saline matter takes place 
within inflamed bloodvessels ; but this statement seems to be no more 
than an assumption to aid his favorite explanation of the obstruction in 
inflammation. 



SECTION XII. 

WATER. 



228. The average proportion of water in healthy blood may be stated 
at about 80 per cent. It is obvious, from what has been already noticed, 
that this proportion increases as that of the animal contents decreases. 



144 ULTIMATE ELEMENTS OF DISEASE. 

Thus, after extensive liemorrhages, and in chlorosis and other cachectic 
states attended with anaemia, the blood is more watery than usual. The 
effect of this state of the blood is to cause a tendency to dropsical effusions 
and fluxes, besides the consequences which result from a deficiency of 
the other constituents of the blood. 

229. I have before suggested a question (§ 187), whether the serious 
functional disturbance sometimes followinoj the inojestion of verv larg-e 
quantities of liquids, particularly after exertion, when absorption is 
active, may not in some degree arise from the too copious and sudden 
addition of water to the blood. Certainly temporary plethora, with 
palpitation, feeling of oppression or dyspnoea, often results from the 
too free ingurgitation of liquids, and is not removed until perspiration, 
or a free flow^ of urine, reliev^es the distended vessels. These symptoms 
are most distinctly observed where some permanent disease of the organs 
of circulation or respiration incapacitates them for the increased task. 
Hence the aggravation of the symptoms of disease of the heart and 
lungs, by too much drink. The colliquative sweats in phthisis seem to 
arise from a similar cause, and may often be relieved by a judicious 
reduction in the quantity of liquid food. 

230. Deficiency of luater in the blood is exemplified in epidemic cho- 
lera, in which the specific gravity of the serum has been found as high 
as 1045 (Lecanu), which implies a reduction of nearly half the natural 
proportion of water. Some diminution probably takes place in other 
diseases attended by profuse watery discharges, such as diarrhoea, dia- 
betes, and excessive sweating. In these cases, the smallness of the 
pulse, and sometimes the shrunk appearance of the surface from the 
undistended state of the vessels, are signs of the diminished bulk of the 
circulating fluid ; and thirst pretty constantly points out the mode 
which nature prompts to remedy the defect. In the same way, exposure 
to heat, especially if continued, and prolonged violent exercise, expend 
the water of the blood, and cause the feeling of thirst through w^hich it 
may be restored. Long abstinence from liquids has a similar effect. 

It has been already mentioned, that the extraordinary decrease of 
the water of the blood which occurs in malignant cholera, renders the 
blood so thick that it cannot circulate freely, and this change is the 
chief cause of the cessation of the pulse, lividity, and other signs of 
obstructed circulation. No such effect is known to follow from any of 
the other causes of deficient water. The operation of heat and con- 
tinued exertion is not simple, and therefore not referable to this prin- 
ciple only. Abstinence from liquids for two or three days induces 
languor, small and easily accelerated pulse, a somewhat pasty state of 
the mouth, and scantiness and turbidity of the urine, but little derange- 
ment of other functions. The digestive process, which might be expected 
to suffer, in some cases at least, shows no symptoms of disorder. 

231. We thus have means of increasing or reducing the water of the 
blood by increasing or diminishing the liquids drank ; and these expe- 
dients may be usefully employed in the cases above mentioned. But 
these expedients in their extremes also furnish us with therapeutic agents 
of more extensive power. Drinking large quantities of water may, in a 



CHANGES IN THE BLOOD — BY RESPIRATION. 145 

salutary manner, excite the whole vascular system and its connected 
secreting organs, and may thus wash out of the blood various eiiete or 
noxious matters; and this is a chief good which the "water-cure" 
sometimes effects. The free use of liquids is supposed, by Prout, to 
prevent the formation of lithic acid, or, according to Liebig, it facili- 
tates its conversion into urea. On the other hand, a total abstinence 
from liquids for two or three days, is an effectual mode of stopping 
fluxes, and of relieving catarrhal inflammations and congestions. Either 
plan exerts an alterative operation on the circulation and secretions, 
which, if more studied, may perhaps be turned to good account in the 
treatment of many diseases. 



SECTION XTII. 

CHANGES IN THE BLOOD BY RESPIRATION. 

232. The process by which venous blood is made arterial, and rendered 
fit for its purpose of maintaining the life and functions of the several 
parts of the body, is liable to variations : and the resulting differences 
in the state of the blood form an important element of disease. 

The conversion of venous into arterial blood comprises the absorption 
of oxygen, the removal of some carbonic acid and water, a slight in- 
crease of fibrine, and possibly other changes. Each of these elements of 
the process is probably concerned in giving to arterial blood its fitness 
for its function ; the absorbed oxygen, by its affinity for the hydrogen 
and carbon of the blood and textures, aiding in those processes by which 
these are renovated in function as well as in structure, superfluous fat, 
and other combustible matters consumed, and heat is evolved ; the re- 
newal of fibrine supplying the expenditure of the plasma, particularly in 
the muscles ; and the removal of the carbonic acid being the excretion 
of a noxious matter. 

233. It is doubtful whether this change is ever carried on in excess ; 
for, by an admirable adaptation, the activity of respiration is propor- 
tioned to the rapidity of the circulation and the corresponding need of 
change in the blood. Thus exercise, which accelerates the circulation 
and changes of the blood, also augments the breathing movements. In 
fevers, also, the frequency of the pulse and of respiration is increased ; 
but the muscular strength being much impaired, it is doubtful whether 
the rapidity of the circulation or the real amount of the respiratory 
changes is generally augmented in proportion. It has been said that, 
in acute rheumatism, the circulation and respiration are too active for 
the wants of the system, and that the blood reaches the veins without 
having wholly lost its arterial character. If this were true, it might in 
some measure explain the great increase of fibrine in the blood in this 
disease ; but the fact is not well established.^ 

' It seems to me that Professor Liebig has given too mechanical a view of the change 
of the blood in respiration. He appears to consider the increased arterialization of blood, 

10 



146 ULTIMATE ELEMENTS OF DISEASE. 

234. Defect of the cliange in the blood bj respiration is a common 
and important element of disease, and constitutes a chief feature of affec- 
tions of the respiratory apparatus. Being the essence of the special 
disease asphyxia^ or apnoea^ its minute consideration belongs to special 
pathology, and we shall here only describe it in its more general cha- 
racters. 

The amount of mischief arising from defective respiration, varies 
greatly according to the sudden or the gradual supervention of the de- 
fect. An acute attack of the organs of respiration may prove distressing, 
and even fatal, by an impediment to the breathing, much smaller than 
that caused by chronic diseases, the gradual infringement of which may 
be scarcely perceived. Thus, too, persons affected with extensive emphy- 
sema of the lungs, are habituated to an imperfect state of respiration, 
which is shown by a constant lividity of the lips and cheek ; such an 
appearance would be a sign of approaching death in other persons. The 
cause of this difference is not merely the general fact that sudden changes 
produce more effect than slow changes, but it lies chiefly in the fact that 
the importance of the respiratory function varies under different cir- 
cumstances. When the several parts of the body, especially the mus- 
cular, are in a state of full activity, more breath is needed to remove 
from the blood the noxious effete matter which always results from func- 
tional exercises. Hence in such a condition (which is that of healthy 
action), the respiratory process cannot be abridged without serious dis- 
order. This disorder is first obvious in the increasing feelings of oppres- 
sion and suffocation which the want of breath causes, and which excite 
forced exertions to breathe. If these exertions still fail to duly aerate 
the blood, it is partly arrested in the lungs, right compartments of the 
heart and veins, and part passes in an imperfectly arterial state to the 
left side of the heart and arteries. 

235. The phenomena of asphyxia are thus compounded of : 1, accu- 
mulation of blood in the venous system ; 2, diminution of blood in the 
arterial system ; and 3, deficiency of oxygen and excess of carbonic acid 
in the blood. These several conditions cause injury to the vital func- 
tions, both by the want of a due supply of blood, and by the bad quality 
of that blood, which is injurious — negatively, for want of oxygen, the 
proper exciting agent, and positively, from its excess of carbonic acid 
and other excrementitious matters, which are sedative. The symptoms 
induced are also of two classes: 1. Those implying failure of function; 

during exercise, and on exposure to cold, to be a necessary consequence of the greater 
amount of air inhaled, in one case by accelerated movements of the chest, in the other, by 
the greater density of the cold air. But if the extent of the changes wrought by respira- 
tion were in exact proportion to the quantity of oxygen received into the lungs, how easy 
would it be to increase them (and therebj'' animal heat also) by voluntarily augmenting 
the respiratory movements. I cannot but think that the proportion of oxygen absorbed, 
and of carbonic acid expired, depends more on the condition of the blood brought to the 
lungs, and that the respiratory movements are regulated by this. Thus the increased 
oxygenation of the blood is a consequence of greater changes previously wrought in the 
blood itself, and not a mere result of a fuller access of air. In confirmation of this view, 
I may mention an experiment wliich any one can repeat ; if a succession of moderately 
deep and cjuick respirations be performed during several minutes, at a pretty low tempe- 
rature, tlic elloct is to cause feelings of chilliness and faintness, rather than of increased 
warmth and energy ; it is like extinguishing a fire by overblowing it. 



CHANGES IN THE BLOOD — BY RESPIRATION. 147 

such as muscular debility, feeble action of the heart, pallor and coldness 
of the surface and extremities, and abolition of the senses and mental 
faculties ; and, 2. Those arising from congestion and the noxious influence 
of the black blood ; such as palpitation, flashes in the eyes, noises in the 
ears, delirium, muscular spasms, &c. Each of these set of symptoms 
may predominate in different cases, and this causes a variety in the phe- 
nomena of asphyxia, which has not been sufficiently noticed by writers 
on this subject. 

236. But we have to notice the other mode in which the changes by 
respiration may become defective, that occurring gradually, or when the 
functions are not active. It is well known that hybernating animals 
breathe scarcely at all, and yet they live ; and this is obviously because 
their functions are reduced to an extremely torpid state. So, too, 
animals newly-born will bear the privation of air for a much longer 
period than those which are older ; and it has been supposed that, in 
adults, failure of the heart's action by syncope retards the operation of 
asphyxiating causes. — (Dr. Carpenter on Asphyxia, Library of Med. 
vol. ii.) 

237. Although a man cannot be reduced to the torpidity of hyberna- 
tion, yet it is certain that he may be brought to bear a defect in the re- 
spiratory changes, which would be fatal in a few minutes under common 
circumstances. This is seen when the defect is congenital, as in those 
affected with malformations of the heart causing cyanosis; and it is also 
seen where the defect is very gradually induced, as in the case of em- 
physema of the lungs. 

238. In cases of cyanosis (the blue disease, in which, from malform- 
ation of the heart some venous blood passes into the arteries), we 
have the opportunity of observing the more essential eff'ects of defective 
arterialization of the blood. Individuals thus aff<ected, are in a lower 
scale of animation. The slower processes of nutrition and secretion 
seem to go on pretty well, but the muscular power is low ; slight exer- 
tions bring on symptoms of faintness, palpitation, suff'ocation, or insen- 
sibility ; the animal heat is lower than natural, and there is greater suf- 
fering from the influence of cold. In short, all the powers of body and 
mind are slender, and are easily disordered by any circumstances which 
tax their activity. In the few that reach mature age, there is no sexual 
passion, which seems to be a happy provision against the chance of per- 
petuating a race of malformed beings — human reptiles. The subjects 
of cyanosis are said to be very liable to hemorrhages, and when these 
occur spontaneously, or from accidental causes, it is very difficult to 
stop them. This must be ascribed to the deficiency of fibrine, which we 
have already found to occur where the changes of the blood l3y respira- 
tion are imperfect (§ 196). The same peculiarity occurs in the foetus. 

[The author here adopts the' old, and now almost exploded, pathology 
of congenital cyanosis. It has been satisfactorily shown by Drs. John- 
son, of London, West, Moreton Stille, and Dunglison, of Philadelphia, 
Craigie, of Edinburgh, Louis and Yalleix, of Paris, and particularly 
Norman Cheevers, of London, with many others, that this aff'ection is 
not due to the direct admixture of venous with arterial blood — at least, in 
a large majority of cases. Louis was the first, we believe, to show that 



148 ULTIMATE ELEMENTS OF DISEASE. 

an opening might exist between the right and left sides of the heart, 
without the production of the cyanotic hue ; and, that this condition 
might be present without any malformation of that organ. His observa- 
tions, made prior to 1826, have been since abundantly confirmed by the 
authorities above quoted. The same distinguished observer then ex- 
pressed the opinion that, in many cases, the disease in question was 
caused by congestion, due to some impediment in the venous circulation. 
Dr. Moreton Stills, in an able inaugural essay on Cyanosis, attempts 
to show, by the analysis of a number of cases, that the pulmonary artery 
was uniformly either imperforated, contracted, or obstructed, or that 
some physical obstacle to the natural course of the blood of analogous 
action existed, and " that the essential characteristics of cyanosis are 
constituted by general venous congestions," and " that it depends simply 
upon any cause which, acting at the centre of the circulation, will pro- 
duce a stasis of venous blood in the capillary system."^ The extensive 
researches of Dr. Norman Cheevers^ confirm the views held by Dr. 
Still^.— C] 

239. In connection with the scantiness of fibrine in the blood, when 
the respiratory changes are defective, we must notice the weakness of 
the muscles generally, which are probably nourished by the fibrine. This 
weakness is often observed in the subjects of extensive disease of the 
lungs, especially emphysema. In these same subjects, the deposition of 
fat is, on the other hand, often excessive, which agrees very well with 
Liebig's idea that respiration directly consumes the oily parts of the 
blood ; the respiration being defective, the fat accumulates (§ 224). 

240. Remedial Measures. — Besides the obvious indication of endea- 
voring to restore the respiratory function where it is defective, the view 
which we have taken of the mode in which the defect is hurtful (§ 234), 
suggests means by which its injurious effect may be diminished. Thus 
circumstances which lower the activity of the functions, often give relief. 
Of these, complete rest to body and mind, warmth to the surface and 
extremities, whilst air is supplied cool and fresh to the face and air- 
passages ; and various sedatives, which reduce the circulation and other 
functions to a lower standard (or, in the language of Laennec, diminish 
the want of breath), such as digitalis, conium, hyoscyamus, &c., are the 
chief. Other medicines, such as ether, belladona, stramonium, lobelia, 
&c., which sometimes relieve dyspnoea, probably act in another way, by 
relieving spasm or other impediments to the respiration. 

241. In extreme cases bordering on asphyxia, the enfeebled circula- 
tion may require stimulants (§ 235), and the engorgement of the venous 
system may indicate depletion ; in different instances, each of these con- 
ditions may most need attention, and sometimes both must be treated in 
the same case. It appears from the researches of Chossat, Erichsen, 
and others, that no stimulant is so generally useful as that of heat to 
the whole body ; and in the experience of the oflQcers of the Royal 
Humane Society, the warm-bath has been found the most useful remedy 

' Am. Journ. Med. Sciences, N. S. vol. viii. p. 25, 1844. 
2 Lond. Medical Gazette, March, 1847. 



CHANGES IN THE BLOOD — BY RESPIEATION. 149 

in restoring animation suspended by submersion. Warm frictions, and 
stimulating applications, are likewise very serviceable in exciting the 
failing circulation. 

242. Experience has not yet furnished us with the means of arterial- 
izing the blood by any other process than that of respiration. This 
process may, in some cases, be aided artificially, either by mechanical 
means, as inflation of the lungs, electricity applied to the muscles of 
respiration, the diaphragm, and abdominal muscles alternately ; and by 
bronchotomy ; — or by chemical means, the supply of oxygen or nitrous 
oxide for respiration. Whether the internal administration or the 
injection into the veins of saline and other matters, containing much 
oxygen in loose combination, such as the chlorates, nitrates, and some 
peroxides, may be made in any degree to supply the defect of respira- 
tion, is uncertain, but it deserves more extensive trials than it has 
received. If these matters could furnish oxygen to the blood, they 
would yet leave undone the other office of respiration, the removal of 
carbonic acid. Might this be accomplished by the administration of 
free alkalies ? In some cases of asphyxia by carbonic acid gas, I have 
thought that some benefit in the progress towards recovery, was derived 
from the use of liquor potassse, with chlorate of potash. Perhaps warm 
baths containing these ingredients might be of some use. Friction of 
the surface of the body, with solutions of these and similar matters, 
might also prove serviceable. 

243. The congested state of most organs which occurs when the 
respiratory process is imperfect, renders necessary remedies suited to 
remove this state ; and it is from a disregard of this consequence of 
imperfect breathing, that many fall victims to the secondary efi"ects of 
apnoea. The lungs, the brain, and the liver suffer most. The best 
remedies in these cases are mercurial and other medicines, which act 
freely on the secretions (§ 173). Probably, these remedies act, in part 
by making the liver assist the lungs in the office of decarbonizing the 
blood. The speedy relief afi'orded to dyspnoea by a bilious diarrhoea, 
has several times seemed to me to countenance this notion. 

244. When, from disease, the respiratory changes are reduced to a 
narrower sphere, it becomes an object not to increase the hydrocarbon 
of the blood by the use of food with much fat, or containing spirit, but 
to make lean meat, and other fibrinous articles, with farinacea, and fruit 
abounding in vegetable acids, the chief sustenance. 

245. There is little to be said on the subject of excess of changes in 
the blood hy respiration^ as it is not certain that such a condition ever 
exists as an element of disease. It has been supposed, that, in most 
sthenic febrile diseases in which the function of respiration is not im- 
paired, this function must be more active in proportion to the accelerated 
circulation. Acute rheumatism gives an example of this kind, and Dr. 
Christison states that the blood drawn from a vein is much more florid 
than usual. If this be a correct observation, this hyper-arterialization 
of the blood may, perhaps, account for the unusual quantity of fibrine 
which it presents in this disease. I must, however, remark that I have 
found the excess of fibrine in cases in which there had been no remark- 
able acceleration of the pulse or respiration. We shall see, hereafter, 



150 ULTIMATE ELEMENTS OF DISEASE. 

that the increase of fibrine is connected rather with the local inflamma- 
tion than with the fever. 

246. From the experiments of the late Mr. Brougton, it appears that 
when animals are confined in oxygen gas, they, in the course of a few 
hours, die comatose ; the respiration first ceases, whilst the heart con- 
tinues to beat with vigor, and the blood, even in the veins, is quite florid ; 
it also presents the arterial character of very speedy coagulation. It 
appears, then, that excess of oxygen injures first the nervous function 
(§ 154) ; but whether it does so by exhausting it by previous excitement, 
or by the coagulability of the blood, or by the excessive production of 
carbonic acid, is not decided by any known experiment. The last- 
named mode is the most consistent with the related phenomena; it can 
scarcely be doubted that an increase of oxygen in the blood must aug- 
ment the production of carbonic acid ; and that this latter agent may 
asphyxiate independently of the exclusion of oxygen, appears from the 
experiment of Rolando ; he found that the air-tube of one lung of the 
land-tortoise may be tied without materially injuring the animal ; but 
if one lung were supplied with carbonic acid gas, whilst the other re- 
ceived air, the animal died in a few hours. — [Carpenter s Suman Phy- 
siology^ p. 590, 3d Amer. Ed.) 

247. Liebig appears to suppose that the poisonous action of hydro- 
cyanic acid and sulphuretted hydrogen, is due to their rendering the 
iron of the red particles of the blood incapable of absorbing oxygen 
from the air, and becoming thus the medium of its transfer to the blood 
and tissues ; but to this hypothesis it may be objected, that the blood of 
an animal poisoned with hydrocyanic acid, exhibits the usual changes on 
exposure to the air. Sulphuretted hydrogen does seem permanently to 
injure the composition of the blood, but not of the red particles merely; 
for it renders the blood fluid, as well as of a dirty red color. It does 
not seem consistent with analogy, to exclude the fibrine and albumen 
from a share in the absorption of oxygen, as well as in furnishing the 
material on which that oxygen afterwards acts.^ 



SECTION XIY. 

CHANGES IN THE BLOOD BY EXCRETION. 

248. Having already noticed this subject under the head of diseased 
secretion (§ 158), it will be unnecessary to dwell long on it here. 

The most remarkable instance of change in the blood from disordered 
secretion, is exhibited in defective secretion of itrine (§§ 70, 170). The 
extreme effects of this element of disease were shown in animals in 

> The opinion thus expressed in the former edition, corresponds with the views of Mul- 
der, Scherer, and others, subsequently published; bat these chemists seem to me to go to 
the opposite extreme, in assigning to the proteine the chief share in the process of absorb- 
ing oxygen. Many facts (^^ 183, 188) combine to prove that the red corpuscles are pre- 
eminent in their power to absorb and convey oxygen, although it is by no means certain 
by what chemical property they hold it. 



CHANGES IN THE BLOOD — BY EXCRETION. 151 

which the kidneys had been extirpated, in the experiments first performed 
by Prevost and Dumas. On the third day after the operation, there 
came on vomiting, diarrhoea of a copious brown liquid ;^ fever, with heat 
varying sometimes as high as 110°, and sometimes as low as 92" ; pulse 
very small and frequent; breathing labored ; death ensued from the fifth 
to the ninth day. After death, there were found efiusion of serum in 
the brain, copious mucus in the bronchi, and bilious fluid and feces in 
the intestines. The liver appeared inflamed (?) and the urinary bladder 
much contracted. The blood was more watery than natural (§ 122), and 
was found to contain urea : five ounces of blood of a dog yielded twenty 
grains of urea ; and two ounces of cat's blood, ten grains. 

249. The symptoms induced in defective secretion of urine by degene- 
rative disease of the kidneys, are very similar to those just mentioned, 
but more diversified, from the defect taking place in difi'erent degrees as 
to amount and time. Thus, in acute cases of albuminuria, or acute 
aggravations of old ones, there may be epileptic convulsions, low delirium, 
and other typhoid symptoms passing into coma (§ 129), sufi"ocative catarrh 
obstinate vomiting, diarrhoea, or inflammatory efl"usions in the serous 
cavities, any of which may end in death. In slower cases, cachexia 
and dropsy may ensue, the blood and solid structures becoming altered. 
All these efiects may be traced to excrementitious matters being retained 
in the blood, especially urea, which has in very many instances been 
detected in considerable quantities ; in the greatest amount acting on the 
nervous system as a narcotic poison (§ 129)|; in smaller, acting as an 
irritant, inducing low inflammations in various membranes and viscera ; 
and in still lower degree causing sundry functional disorders, fluxes, and 
dropsies, impoverishing the blood, and inducing degeneration of certain 
textures (§ 212). It has been already mentioned that the blood in al- 
buminuria loses its proper amount of red particles (§ 185), and of albumen 
(§ 222), and the diminution of these assists in accounting for the weak- 
ness, dropsy, and degenerations which commonly ensue in protracted 
cases. The several results now enumerated may be difi'erently pre- 
sented in difi'erent cases, and the treatment should be guided according 
to them. 

250. The efi*ects on the blood of a defective secretion of bile have not 
been so accurately determined. The presence of the bile is often obvi- 
ous in the yellow color of the serum and fibrine, which gives the charac- 
teristic green on the addition of nitric acid, and in such cases, analysis 
has discovered, besides the bilin and the biliphsein, an increase of fatty 
matter to double or treble the ordinary proportion. In several cases of 
fatal jaundice connected with structural disease of the liver, I have ob- 
served extensive ecchymoses on the legs, which probably are due to the 
destructive influence exercised by bile on the red particles (§ 187) ; and 
I have already stated (§ 171), that in most of the cases of purpura which 
I have seen, there has been imperfect action of the liver, and the most 
efi*ectual treatment was by medicines which this circumstance would sug- 

' From the recent researches of Bernard and Barreswil, it appears that the matter ex- 
creted from the intestines contains a quantity of ammoniacal salt, which results from the 
elimination of urea from their surface. — Br. Day's Lectures on Animal Chemistry, Med. 
Gaz. Sept. 1847. 



152 ULTIMATE ELEMENTS OF DISEASE. 

gest. The presence of bile in the blood, although sometimes causing 
tingling, pruritus, and cutaneous eruptions, does not appear to produce 
local irritation and inflammation, or change of the blood and general 
dropsy, so remarkably as that of urea does. Still, it appears from very 
prolonged cases of jaundice, in which the dropsy is not local merely 
(ascites), but general (anasarca and hydrothorax), that the blood at last 
is impoverished, and the whole body becomes cachectic. Andral found 
that in dropsical sheep, with flukes in the liver, the albumen, as well as 
the red particles of blood, was diminished. Symptoms of giddiness, 
faintness, and drowsiness, often occur in connection with imperfect action 
of the liver, such as is commonly designated by the term bilious attacJc, 
and are relieved by medicines which promote a free flow of bile ; but 
whether they are caused by retention of the excrementitious matter in 
the blood, or by the sympathy (§ 152) of the brain and heart with the 
stomach and liver, is uncertain. 

251. Th.Q perspiratory secretion contains lactic acid and lactates of soda 
and ammonia, which probably proceed from the transformation or decay 
of the textures, particularly the muscular, which the recent researches 
of Liebig have shown to contain a preponderance of this acid [Chemistry 
of Food, &c., 1847). Hence these products abound during great mus- 
cular exertion ; and when perspiration is checked by external cold (§ 77), 
they may be retained in the blood, causing rheumatism, urinary dis- 
orders, or various cutaneous diseases. The very serious effects some- 
times resulting from sudden cold on the perspiring body may be partly 
owing to the same cause, as well as to the disorder produced in the circu- 
lation.^ Rheumatism is especially liable to occur as an effect of cold, 
where the body is fatigued with much muscular exertion (§ 30) ; and I 
have frequently observed that the rheumatism chiefly afl^ects the limbs 
which have been most exercised. Where the skin fails to excrete, an 
increased task is thrown on the kidneys, whence may result various 
diseases of these organs ; and if these organs fail in the task, the lactic 
acid accumulates in the blood, and probably acting as a ferment (§ bQ\ 
causes the formation of more, and of the kindred products, lithic acid 
and its compounds and products ; these, in inflammatory subjects, excite 
rheumatic fever ; in cachectic persons, miliary fever, erysipelas, or pem- 
phigus ; and in more torpid frames, various local rheumatic or gouty 
affections. All these cases are frequently remarkable for the acid cha- 
racter of the cutaneous and renal excretions,^ and in a few instances the 
blood has been found to possess acid qualities, or to be deficient in its 
usual alkaline reaction. [Dr. Bay's Vogel [p. 84, Am. Ed.]). In low 
forms of rheumatism, especially the neuralgic, the materies morbi is pro- 
bably oxalic acid, as originally suggested by Dr. Prout, for I have in 

' Dr. R. Willis has recently suggested that checked perspiration may prove hurtful hy 
rendering the skin dry, and therefore unfavorable for vital changes supposed to take place 
in the cutaneous capillaries. But if this were the only or chief cause of mischief, it might 
be always reinovcd by the warm bath, or any other means of moistening the surface; in 
like manner, pernicious effects should always result from a dry state of the skin ; neither 
of these consists with facts. 

2 In patients with acute rheumatism, I have fx-equently found the perspiration of the 
affected joints more strongly acid than on other parts. 



CHANGES IN THE BLOOD — BY TRANSFORMATION. 153 

numerous instances found an abundance of the octahedral crystals of 
oxalate of lime in the urine, especially when the patients begin to con- 
valesce. 

252. The remedy for rheumatism and other diseases arising from de- 
fective excretion, therefore, should not be merely antiphlogistic, but also 
of a kind calculated to eliminate the morbid matter from the blood. In 
slight cases of rheumatism, sudorifics may suffice ; but in others, the 
kidneys and liver should also be excited to assist in the process of elimi- 
nation, and various combinations of colchicum and alkalies with mercury, 
opium, and iodide of potassium, will generally effect this purpose very 
satisfactorily, and both speedily and permanently remove the disease.^ 
Where the disease is more decidedly asthenic, and the urine exhibits a 
deposition of oxalate of lime with or instead of lithates, or acid phos- 
phates, great advantage may be often derived from the use of means cal- 
culated to raise the tone and vital energies of the circulating and secret- 
ing organs, such as bark, quinia, arsenic, and iron ; and they are the 
more eligible in cases of neuralgic rheumatism, because the attacks are 
periodic, with intervals of depression highly favorable to the use of 
these remedies. 



SECTION XY. 

CHANGES OF THE BLOOD FROM THE TRANSFORMATION OF 
CHYLE AND OF THE TEXTURES. 

253. The changes of the blood from the transformation of the chyle 
and of the textures, including the processes of nutrition and reparation, 
have been examined too little to supply the pathologist any certain data. 
Prout, Liebig, and other organic chemists, have advanced interesting 
views on these subjects, but they are too hypothetical to be strictly 
applicable to medicine. It seems quite warrantable, however, to connect 
w^ith these changes some remarkable states of disease, on the pathology 
of which chemistry has thrown much light, gout and other lithie acid 
diseases (§ 176), diabetes^ both saccharine and ureal, and obesity. 

254. Gout, and the commonest kind of urinary gravel, are now gene- 
rally considered to depend on the production in the system of an excess 
of lithie acid.^ This acid being a highly azotized compound, is abund- 
antly generated in those who take a large proportion of animal food, 
and in whom the digestive and assimilative processes are impaired ; and 

1 The advantages of tliis due regard to the essential elements of disease in the treat- 
ment of rheumatism, may be shown by the fact, that, iu upwards of two hundred cases of 
various forms of rheumatism, under my care in University College Hospital, the convales- 
cence was established in from three to six days on an average, and the patients were 
dismissed cured in from one to three weeks after. 

2 This view, although generally admitted on inferential evidence, has lately, for the first 
time, received a demonstration of its truth, in the case of a gouty patient of mine at the 
hospital, in whose blood Dr. Garrod readily detected the presence of lithie acid. The case 
was of chronic gout; and farther illustrated the pathology of the disease, by a total 
absence of lithie acid in the urine, until during the exhibition of colchicum, when its cha- 
racteristic crystals appeared under the microscope. 



154 ULTIMATE ELEMENTS OF DISEASE. " 

the more the processes are weakened, and the less digestible and assi- 
milable the food supplied to them, the more surely will this acid with 
ammonia, the products of degenerating decomposition, result. Hence 
it is engendered not only as a consequence of general full living and 
sedentary habits, but especially from highly-seasoned and over-cooked 
meats, cheese, pastry, strong acid wines, &c. ; and the avoidance of 
such articles is a more effectual safeguard against gout, than general 
abstinence, which, in many cases, is absolutely hurtful. Lithic acid is 
one of the lower forms of animal matter into which the higher princi- 
ples, fibrine, albumen, gelatine, &c., tend to pass, in their progress 
towards dissolution. Hence it is produced in excess, where there is 
more azotized matter than is wanted for the reparation of the textures, 
or than the vital assimilating powers can appropriate for this purpose. 
But it probably results also from the decay of the textures, especially 
during febrile or inflammatory irritation, during and after which copious 
deposits of the lithates are seen in the urine. 

The morbid effects of an excess of lithic acid will vary considerably, 
according to its amount and other circumstances. The kidneys are the 
proper emunctories by which it is eliminated from the blood, and these 
sometimes suffer from the irritation which it causes ; hence nephralgia 
and nephritis^ may occur ; or the water and alkali secreted with it in the 
urine may be insufficient to hold it in solution, and it may be deposited 
in the form of crystallized sand or gravel, or calculus, in the kidneys or 
bladder ; and various irritations and obstructions in the urinary appara- 
tus may be the result. 

But sometimes the kidneys may fail in their power of elimination 
(§ 170); the lithic acid and its compounds then accumulate in the blood, 
and may cause various irritations and functional derangements (irregu- 
lar gout, which is extremely common, and of infinitely various form and 
seat), until at length some circumstance may fix the irritation in a limb, 
and a fit of regular gout is the consequence. In this fit, if perfect, in- 
flammation is excited with more or less febrile disturbance, which ends 
with a copious deposit in the urine, showing the removal of the morbid 
matter (§ 165). The more acute and fixed the inflammation, and the 
smarter the fever, the more abundant is the deposit, and the more free 
is the patient from disease afterwards. On the other hand, when the 
inflammation is low, changing its place, and with little fever, it gene- 
rally tarries long, and the system is not relieved. It is when gout thus 
lasts long, or frequently recurs, that often its material so accumulates 
in the joints as to be deposited in the form of a plastery or calculous 
matter, consisting of lithate of soda (chalk stones of gout).^ This 
chronic form of gout is connected with a more or less permanent dis- 

' I have in several instances found in the cortical and tubular structure of the kidney, 
clustered crystals of lithic acid, which, under the microscope, exhibited such sharp angles 
and dagger-shaped projections, as would afford an easy explanation of the pain, inflam- 
mation, and hemorrhage, often attendant on an attack of renal gravel, even Avhen none is 
obvious in the urine. 

2 A case of chronic gout at present (June, 1847) under my care, has afforded an op- 
portunity of verifying this observation; the matter obtained by puncturing the white 
tumors of his fingers, is of the consistence of thick cream, and consists of very fine 
acicular crystals of lithate of soda, with a trace of lime. 



CHANGES IN THE BLOOD — BY TEANSFORM ATION. 155 

order of the digestive or assimilative functions, whicli renders its treat- 
ment more difficult or less successful than that of the more acute forms 
of gout. In such cases (chronic), lithic acid seems to be engendered 
in great abundance, and although thrown off in large quantities in the 
urine for an indefinite period, yet never leaves the body free. Such 
cases are commonly either hereditary, or those which have been ren- 
dered inveterate by intemperate habits, or neglect of proper treatment. 
255. In saccharine diabetes, the morbid matter is of a nature quite 
contrasted with that of gout and gravel, being grape sugar, which is 
wholly unazotized; yet this is also probably produced in connection 
with the processes of digestion and assimilation — the condition of the 
urine being only a consequence of disorder in these processes. The 
analyses of Ambrosiani, Maitland, and others, have proved the existence 
of sugar in the blood of diabetic patients, the specific gravity of the 
serum of which may rise to 1060 from its presence ; and Macgregor 
has also established the fact of its unusual production during the pro- 
cess of digestion. The facility with which, in the laboratory, starch 
and gum can be converted into sugar, especially under the action of 
acids, throws much light on the origin of sugar in diabetes ; and the 
actual presence of a very large amount of acid in the stomach in dia- 
betic patients, confirms this mode of explanation. The appearance of 
sugar in the urine can scarcely be considered otherwise than as a result 
of its presence in the blood. But it is probably formed not only from 
isomeric principles in the food, such as starch and gum, but in confirmed 
cases it is also derived from a decay of the textures, especially the 
gelatinous, by a modification of the process in which urea is naturally 
evolved, as it has been found practicable to convert gelatine partially 
into glucocol, which has saccharine properties, and probably consists of 
sugar and urea. As there is saccharine matter naturally in chyle (and 
even in blood, for a short time after the chyle is added to it), it might 
be supposed that there is, in incipient diabetes, an exaggeration of the 
process by which saccharine matter is formed; and this is countenanced 
by the fact, ascertained by Bouchardat, that the sugar in the blood of 
diabetic patients is at its maximum during the process of chylification, 
and that it almost disappears after a long fast.^ It is, therefore, pro- 
bable that the atrophy and cachexia accompanying the disease, result 
from the draining away of the nourishment of the body ivitli the excess 
of sugar, rather than the conversion of all this nourishment into sugar. 
It is now well ascertained that the ordinary animal constituents of the 

' [The contradictory results obtained vrith regard to tlie presence of sugar in the blood 
of diabetic patients, is due, chiefly, according to M. Bouchardat, to the following circum- 
stance. If you examine diabetic urine at different periods of the day, you will find that 
an hour or two after meals it is abundantly secreted, contains a considerable proportion 
of sugar, which successively decreases for the next twelve or fifteen hours ; beyond this 
term, if the patient has eaten nothing, no trace of sugar will be found in the urme. 
Patients are ordinarily, in hospitals, bled in the morning, the period most distant from 
their meals, and the amount of sugar then in the blood is so minute as to escape detection. 
By two comparative analyses, M. Bouchardat sustains his position. In a patient, bled at 
nine o'clock in the morning, who had fasted since five o'clock the previous evening, no 
trace of sugar was detected. In another patient, bled two hours after a light breakfast, 
there was unequivocal evidence of sugar in the blood. These observations of M, 
Bouchardat have been corroborated by Simon. — C] — Animal Chemistry, p. 267, Am. Ed. 



156 ULTIMATE ELEMENTS OF DISEASE. 

urine are not only present, but are often increased considerably beyond 
their natural amount. 

256. There is a parallel between the indications of treatment in gout 
and in diabetes, although, in the fulfilment of these indications, the 
means to be employed are most opposite. In both cases we must with- 
hold those articles of diet from which the morbific matter is most readily 
generated. Thus abstinence from animal food and stimulating condi- 
ments and beverages, in the case of gout — the exclusive use of these 
very articles, to the avoidance of all saccharine or amylaceous substances 
in the case of diabetes — constitute a successful part of the treatment. 
In both cases, it is indicated to improve those processes of digestion 
and assimilation from a perversion of which the morbid matter is pro- 
bably generated. But, unfortunately, we know too little of these pro- 
cesses and of means which may influence them, to enable us to fulfil this 
indication with certainty. A gouty constitution, in the absence of the 
febrile paroxysms, is often much corrected by the use of bitters and 
other mild tonics ; and in diabetes, an amendment occasionally takes 
place during the exhibition of opium and some of the stronger astrin- 
gents and tonics, such as preparations of iron, copper, &c. In both 
gout and diabetes, the mal-assimilation seems to be connected with an 
unusual development of acidity in the system, and in both diseases 
alkalies have been found to be useful ; and for reasons presently to be 
mentioned, soda and potass are more suited to gout, and ammonia and 
magnesia or the alkaline phosphate of soda, succeed best in diabetes. 
To take full eifect alkalies must be given largely, in the form of their 
carbonates. 

In the effect which each exerts on the economy, there is a great 
difference between the morbid matter of gout and that of diabetes. 
The sugar in the latter has no tendency to accumulate in the system 
and produce local effects ; but, acting as a powerful diuretic, it passes 
rapidly away, carrying with it a great quantity of water, and of the 
other constituents of ordinary urine (§ 165) ; and the thirst, dry skin, 
and emaciation of diabetes, seem to be chiefly due to this mode of ope- 
ration. The common complication of diabetes with pulmonary consump- 
tion shows also, however, that the plastic process is degraded (§ 211). 

The lithic acid of gout and gravel, on the other hand, has a tendency 
to accumulate in the body, and to cause the local and general irritations 
which have been already mentioned (§ 254). Hence it becomes a chief 
indication to counteract its irritating properties, and to promote its 
elimination from the system. The medicines which are most efiicacious 
in doing this are alkalies, or their carbonates, or their vegetable salts, 
with colchicum, or iodide of potassium, saline mineral waters, and altera- 
tive aperients. These all increase the action of the kidneys and intes- 
tinal canal, and drain off the offending matter from the system ; but 
the operation of colchicum is far more certain than that of the others ; 
and its permanent cflicacy depends on its continued action on the kidneys 
in particular. 

257. It is supposed by most chemists, that the urea excreted by the 



CHANGES IN THE BLOOD — BY TRANSFORMATION. 157 

kidneys is chiefly derived from the transformation or decay of the textures 
of the body (§ 254), most of their carbonaceous matter being abstracted 
by the affinity of the oxygen of the blood, and carried off by the lungs 
in the form of carbonic acid gas (§ 232). The causes which increase 
the production of urea are, according to Liebig, those which excite the 
activity of the function of respiration, which supplies the consuming 
oxygen, especially active bodily exercise. Under some circumstances, 
however, the formation and excretion of urea are much augmented, with- 
out any obvious excitement of the respiratory function. This is the case 
in the diabetes ureosus described by Dr. Prout, and which he considers 
a forerunner of saccharine diabetes. Such spontaneous production of 
the matter which seems to be a kind of debris of the body, indicates or- 
ganic debility, or exhaustion of the vital powers, and has been observed 
to occur in young persons who have grown rapidly, or in those weakened 
by great mental exertion and want of sleep, or by venereal excesses. 
An excessive excretion of urea (or of carbonate of ammonia, which is 
of kindred composition), sometimes takes place in typhoid fevers, and 
is attended with great loss of flesh and strength. A great and sudden 
increase of urea in the urine was ascertained to have taken place, in 
some patients with acute rheumatism, and others with delirium tremens, 
in University College Hospital, at the decline of the fever and other acute 
symptoms. This perhaps ought to be viewed as arising from the removal 
of that which had accumulated, rather than from an increased formation 
of urea ; and this fact may be connected with that ascertained by Pro- 
fessor Chelius and Dr. Lewins, that colchicum causes an augmented dis- 
charge of this and other principles of the urine (§§ 173, 252). 

In cases of excessive formation of urea, all circumstances which de- 
press or exhaust the organic life must be avoided, such as great excite- 
ment of body or mind ; waste must be supplied by a generous diet, and 
the nutritive function sustained by tonics. Opium and other narcotics 
are found to be useful in reducing the urine in the diabetes ureosus ; and 
they probably operate by calming exhausting nervous excitement, and 
procuring sleep. 

258. The eduction or production of fat from food takes place with 
remarkable activity in some persons; and wherever it obstructs or su- 
persedes the proper formation of fibrine and other proteine principles 
more immediately concerned in giving strength to the bodily frame, it 
amounts to disease. The circumstances in the diet tending to this result, 
have been formerly noticed (§§ 59, 60), and we have had occasion to men- 
tion that sedentary habits and a lowered condition of the respiratory func- 
tion, have sometimes a similar effect (§§ 65, 239). But in connection with 
our present subject, there are many reasons for supposing that an excessive 
production of fat sometimes occurs as an error in assimilation, and may 
interfere with the sufficient production of other animal principles and 
with the nourishment of the textures of kindred composition, whilst 
fat accumulates not only in its proper texture, but invades others, low- 
ering their vitality and cohesion, and thus constituting a cause of gra- 
dual degeneration. Thus Mr. Gulliver has shown that the atheromatous 
patches in the coats of arteries, which appear to be a mark of declining 
age (natural or premature), are of the nature of fatty degeneration. The 



158 ULTIMATE ELEMENTS OF DISEASE. 

same pathologist has discovered a predominance of fatty matter (chiefly 
oleine, margarine, and cholesterine), in the lungs, the kidneys, and tes- 
ticles, under various chronic diseases {Med. G-azette, June, 1843). A 
similar abundance of fat has been frequently observed by me (first in 
conjunction with Dr. R. Quain, in May, 1845), in the kidneys, liver, 
and other structures of persons whose habits of excessive intemperance 
proved fatal, with symptoms of general cachexia and failure of many 
functions. This subject will be noticed again under the head of per- 
verted nutrition^ where the remedies to be opposed to the element, fatty 
transformation, will be considered. 



SECTION XVI. 

CHANGED PROPERTIES OF THE BLOOD FROM THE PRESENCE 
OF FOREIGN MATTERS. 

259. The blood is probably the chief seat of the morbid poisons which 
excite various contagious (§ 93), epidemic (§ 88), and endemic diseases 
(§ 81). Probably, too, it is the hotbed in vfhich some of them are pro- 
pagated, whether by seeds, ova, cell-germs, or parasites (§ 99) ; and it is 
through changes in its composition that many of the destructive effects 
of these poisons are produced (§§ 186, 196). We have already noticed 
some of these changes under former heads. It will suffice in this place 
to mention a few examples in which morbid poisons have been traced to 
the blood. 

Dr. Francis Home communicated measles from one person to another 
by inoculating with the blood of a patient affected with the disease. M. 
Gendrin describes the following experiment : A man who had been skin- 
ning a diseased animal was seized with a putrid fever, attended with an 
eruption of sloughing pustules. Some blood taken from this man was 
injected into the cellular texture of the groin of a cat ; the animal was 
soon affected with vomiting of bile, dyspnoea, frequent, small, and irre- 
gular pulse, dry brown tongue, slight convulsions, and died seven hours 
after the injection. The same pathologist produced in animals various 
severe symptoms, speedily ending in death, by injecting into their veins 
blood from a person laboring under confluent smallpox. MM. Dupuy 
and Leuret communicated to a healthy horse the malignant postular dis- 
ease called " charbon," by injecting into its veins blood from a diseased 
animal ; and M. Renault, in a similar way, propagated glanders from one 
horse to another. Andral quotes from Duhamel an extraordinary case, 
in which blistering, pustules, malignant fever, and death, followed the 
mere contact on the lips of the diseased blood of an animal. Other 
instances are on record of sickness, faintness, and serious illness being 
caused hj the odor of blood ; and Dr. Copland quotes from Zacutus a 
marvellous story of three persons being struck dead by the smell of the 
blood of a patient in the plague. 

There is good reason to suppose that purulent matter and the germs 
(^ 90) of carcinoma, and other forms of malignant disease, are spread 



CHANGES IN THE BLOOD BY FOREIGN MATTERS. 159 

through the system through the medium of the blood. Pus has been 
frequently detected in the blood by the aid of the microscope, first by 
Mr. Gulliver, and by many subsequent observers. The pus-globule is 
to be distinguished from the pale or lymph-corpuscle, by its somewhat 
larger size, more distinct and often granular cell-wall, by its contained 
granules or nuclei being more distinct, and sometimes loose in its inte- 
rior ; and lastly, by its exhibiting exosmotic and endosmotic properties 
much more actively. The different effects of pus in the blood will be 
noticed under the head of results of inflammation. The tendency to 
symmetrical arrangement which cutaneous eruptions, nodosities of the 
joints, paralysis from lead, and some other local affections, exhibit, has 
been adduced, by Dr. W. Budd and others, as an instance of effects 
produced through the medium of the blood — the symmetrical distribu- 
tion of this fluid on the opposite halves of the body leading to like re- 
sults in corresponding parts. 

260. In the treatment of this element of disease, foreign morbific 
matters in the blood, the two indications which present themselves are : 
1. To counteract the injurious operation of these matters ; and, 2. To 
expel them from the system. The first of these indications is followed, 
when we give stimulants to overcome the depressing influence of adyna- 
mic fevers and other sedative poisons ; antiperiodic tonics to prevent 
the operation of the paludal poison (§ 81) ; and when opium and other 
narcotics are administered where irritation prevails. We do not possess 
chemical antidotes which can act on the foreign matter in the blood 
without injuring the blood itself. The other indication is more gene- 
rally pursued, although little recognized by practitioners — to expel the 
offending matter from the system. The excretory organs, especially 
the kidneys and alimentary canal, are the natural emunctories through 
which foreign and offending matters are expelled from the blood ; and 
hence the utility of alterative aperients and diuretics (§§ 173, 174), in 
the treatment of fever and other diseases connected with poison or in- 
jurious matter in the blood. Orfila found that the pernicious effects of 
small repeated doses of arsenic in animals might be averted by giving, 
at the same time, a diuretic medicine. Let us bear in mind how often 
fevers and other serious ailments seem to be carried off by spontaneous 
diarrhoea, diuresis, or perspiration ; and, perhaps, sometimes by these 
discharges artificially excited. Nor should a converse fact be over- 
looked, that persons affected with diseases of the kidney, which impair 
its excernent function, are peculiarly liable to contract infectious dis- 
eases, and to suffer from their effects (§§ 17, 26, 32). Similar observa- 
tions may be made respecting various other poisons which operate 
through the blood, such as opium, arsenic, mercury, kc, which operate 
with uncommon, and therefore dangerous energy, on those whose ex- 
creting functions are much impaired. 



160 



CHAPTER III. 

SECONDARY OR PROXIMATE ELEMENTS OF DISEASE, CONSISTING OF 
TWO OR MORE PRIMARY ELEMENTS (§ 304). 



SECTION I. 

ANiEMIA. 



261. The class oi irroximate elements which have been most generally 
studied as the subjects of general pathology, are those affecting the cir- 
culation of the blood. They comprise at least three of the primary 
elements which have been considered — the blood and its constituents, 
the irritability and the tonicity of the organs (§§ 110, 120), concerned 
in its distribution. A previous acquaintance with these elements will 
render very intelligible many of the kinds and phenomena of their com- 

' pounds, but it is necessary to keep in view also the physical properties 
of the vessels and their contents ; for these properties, when altered, be- 
come elements of disease. Thus a mechanical obstruction or an enlarge- 
ment of a bloodvessel contributes to the formation of disease as much 
as a change of vital properties. So it is impossible to understand the 
effects of too much or too little blood in the vessels, without a due con- 
sideration of the mechanism of the circulation. 

We shall briefly consider the morbid conditions connected with defect 
and excess of Mood in the vessels, under the divisions of general and 
partial^ and as attended with an increase or diminution of the irritabi- 
lity and tone of the moving fibre. It is to be understood that all the 
proximate elements of disease now to be considered, may occur either 
as distinct affections or in combination with other maladies. 

262. Anirmia, or as it has been more correctly termed, hypdemia^ or 
alic/dcmia, is the name applied to that condition of the system in which 
the predominant character is a deficiency of blood. And as, together 
with this deficiency in quantity, there is very generally a remarkable 
deterioration in its quality, the late Dr. Simon applied to the condition 
the term spansemia (crtaroj, poor). 

263. The exciting causes of anaemia are, various circumstances which 
withdraw or injure the blood, especially the red particles (§ 71), or in- 
terfere with their formation (§ QCi) ; suchas^excessive bleedings, or hemor- 
rhages ; profuse evacuations of other fluids, which contain much of the 



ANEMIA. 161 

animal parts of the blood; scanty or poor food, especially that which 
contains little animal matter or proteine; confinement in impure air, dark 
places, or malarious districts (§ 191) ; certain chronic maladies which 
deeply afiect the constitution, such as tuberculous and cancerous dis- 
eases, and granular degenerations of the kidneys (§§ 185, 222, 249) ; 
but the commonest cause of all is irregularity of the uterine function, 
which induces the common form of the disease long familiar under the 
designation chlorosis. It might seem difiicult to understand how the 
last operates ; but that, in many cases, it is a cause and not an effect of 
anasmia, is plain from the well-known fact that no signs of anaemia have 
occurred until cold, over-exertion, or mental excitement, or some cir- 
cumstance, has suddenly checked the flow of the catamenia ; it has not 
returned ; and then the patient begins to lose color, and gradually to 
exhibit the anaemic state. In many cases, I have known this occur in 
young females who have previously suffered from acute rheumatism, im- 
plicating the heart. It would seem that, in these cases, some injury is 
done to the blood-particles, and to the powers by which they are repaired; 
this is manifest not only from the pallidity, but from the yellowish and 
almost greenish hue which the complexion sometimes presents, and 
which obviously depends on a discoloration of the textures by the altered 
blood, as in the neighborhood of a bruised part. The nature of these 
changes has been already noticed (§§ 185-6, 191). In some of these 
cases of chlorosis, the appetite is depraved (§ 131) ; there is such a com- 
plete disrelish for animal food and other nourishing articles, and such a 
craving for sour things, and even for matters destitute of nourishment, 
as chalk, cinders, &c., that it might be supposed that this perverted ap- 
petite is the cause of the ansemia, by deterring the patient from taking 
that food which is capable of making red blood ; and undoubtedly such 
an appetite, when indulged, must contribute to this result ; but it is not 
so constantly present as to be considered the chief cause of the anaemia 
in the examples under consideration. 

It is often symptomatic of various maladies, particularly chronic and 
cachectic affections ; but it sometimes occurs without any other known 
disease, and its symptoms exemplify in a striking manner the mode in 
which the various functions sujffer for want of a due supply of the vivi- 
fying fluid (§§ 183, 185). 

Thus the general symptoms of anaemia are those of weakness (§ 116); 
general muscular weakness, evinced by the faintness, breathlessness, 
and fatigue caused by exercise ; weakness of the heart, shown by the 
feeble, loose, or thready pulse, rendered very frequent and palpitating 
by slight exertion, and often irregular and failing afterwards ; feebleness 
of the whole circulation (§ 123), manifest in the coldness of the surface 
and extremities ; organic weakness, shown by the loss of appetite, indi- 
gestion, torpor of the bowels, scanty and disordered secretions (§ 172) ; 
defective nutrition (§ 211), especially of the muscular parts ; and imper- 
fect sanguification; for the remaining blood becomes diseased, being 
poor and watery, as well as scanty (§§ 185, 222). 

264. There are also distinctive physical signs of the scantiness of 
blood in the body ; the surface is remarkably pallid, and even the lips, 
gums, and tongue show none of their healthy ruddiness. The complex- 



162 PROXIMATE ELEMENTS OF DISEASE. 

ion may vary the amount and kind of the paleness, dark persons often 
appearing very sallow, or even of a yellowish or greenish tint, and those 
of fair complexion having a ghostly paleness. If bloodvessels are seen 
at all, it is only the larger superficial veins, which are pink instead of 
blue, from the paucity and transparency of the blood in them. In the 
course of the larger veins, especially the jugulars in the neck, the thin 
blood, running with great rapidity in the ill-filled vessels, is often thrown 
into sonorous vibrations (venous murmurs), which are sometimes sensible 
to the finger placed lightly on the vein. The same thinness of the blood, 
together with an abruptness in the heart's contractions (§ 113), frequently 
causes a murmur with the first sound of the heart, referable to the aortic 
orifice ; as, however, this murmur varies much in different cases, being 
scarcely audible in some, whilst it is loud and harsh in others, it is ob- 
viously dependent in part on some irregularity or narrowing at the mouth 
of the aorta, too trifling to give any obstruction or sound when the blood 
is abundant and of due spissitude, but readily causing vibrations and 
sonorous gushes when the fluid is thin, and the relations between the 
size of the heart and arteries somewhat changed. 

265. The blood, when drawn, is very thin and watery. It readily 
coagulates, and forms a very small contracted clot (§ 207), generally 
covered with a bufl'y coat. This appearance is probably due, as Andral, 
surmises, to a predominance of the fibrine over the red particles, for 
these -are diminished much more than the fibrine, being, in extreme 
cases, reduced to one-fifth of their natural proportion (§ 185). The al- 
bumen is also generally scantier than usual ; a remarkable exception 
in the anaemia attendant on paraplegia has been already noticed (§ 221). 

266. Although the symptoms of anasmia are chiefly those of great 
weakness or depression (§ 262), there are often others of an opposite 
character, indicating irritation or exaltation of function. Some of these 
arise indirectly from the weakness; as, for example, pain in the left side 
and epigastrium, nausea, colic, and diarrhoea (§§ 5Q, 168, &c.), w^hich 
may be traced to the weak digestion leading to the production of sundry 
irritating matters, from that which has been used for nourishment. But 
other more direct signs of excitement sometimes occur. Thus various 
properties of the nervous system are sometimes exalted ; sensibility is 
acute (§ 126) ; there is intolerance of light and sound, with flashes in 
the eyes, noise in the ears, a sense of rushing in the head, and various 
neuralgic pains. The excito-motory nerves are sometimes excited (§§ 
140, 150) ; and spasms, or convulsive aff*ections of diff'erent kinds, may 
be present ; or the organic functions may be aff"ected ; and palpitation, 
spasmodic asthma, vomiting, and such sympathetic irritations may oc- 
cur. In a few instances, anaemia has been attended with delirium, or 
mental excitement bordering on it. 

267. It thus appears that the functions which frequently are thus ex- 
, cited in the midst of general depression and weakness, are those of the 

nervous centres ; and the generally nervous character of persons in a 
state of great weakness (§ 113), is connected with the same fact, so that 
n&i'vousness and weakness are almost synonymous terms. No explana- 
tion of this apparent anomaly has been, to my knoAvledge, proposed ; 
but one seems to suggest itself in the peculiar distribution of the circu- 



ANEMIA. 163 

lation througti the nervous centres. "When the mass of the blood is re- 
duced in quantity, the bloodvessels generally contract in proportion, 
their tonicity adapting them to the amount of their contents (§ 120). 
But the vessels within the skull and spinal canal cannot contract with 
the same facility ; for not being exposed to atmospheric pressure, and 
some of them being fixed in bony canals, they do not shrink as the 
blood becomes reduced, and therefore they retain more than their pro- 
per share of the circulating fluid. ^ This disproportionate amount of 
blood in the nervous centres, produces different effects, according to the 
degree which the heart's propulsive power (§ 111) reaches it. Under 
the influence of temporary palpitation (§ 112), fever, or other kind of 
excitement, the brain and spinal cord, through their uncontracted ves- 
sels, which are among the nearest to the heart, receive an unusual share 
of its exalted but partial force ; an erethism of some one or more of the 
functions of these nervous centres (§§ 127, 133, 153) is the consequence ; 
and pain, spasm, sensorial excitement, intolerance of light and sound, 
or sympathetic irritations of some kind or another, occur.^ In this 
condition, the head may be hot and throbbing, the face flushed, the eyes 
suffused, whilst the extremities and the surface generally are compara- 
tively bloodless, and either cold, or very speedily becoming so, on expo- 
sure. Epistaxis sometimes occurs, and, although bringing momentary 
relief, may, if considerable, add to the evil, by increasing the aneemia. 
268. On the other hand, if the heart's action is feeble (§ 116), it may 
be inadequate to propel the blood accumulated in the vessels of the 
brain ; it therefore stagnates, and may cause some of the symptoms of 
congestion in that organ. Hence headache and giddiness, relieved by 
the recumbent posture, drowsiness, impaired mental faculties, obscured 
vision and hearing, partial paralysis, and in extreme cases, coma or 
catalepsy (§§ 129, 133, 141). In such cases, the blood is accumulated 
more in the veins and sinuses of the brain than in its arteries, and not 
receiving enough force from the heart to keep it in full motion, it par- 
tially stagnates, and the functions of the corresponding parts are im- 
paired in proportion. This congestion may be only temporary, and 
lead to no serious results ; but in some cases I believe there occurs an 
event that has not been noticed by pathologists — namely, a coagulation 
of the blood in the sinuses, and a consequent permanent obstruction to 

1 This statement is not invalidated by the recent experiments of Dr. Gr. Burro-n-s, (Med. 
Gaz. April, 1843, {^Disorders of the Cerebral Circulation, &c. &c., Phil. 1848.]) His ex 
periments and expositions verv satisfactorily demonstrate the absurdity of the notions, 
founded on Dr. Kellie's paper, that the quantity of blood in the head isal'^'ays the same: 
but it remains clear, that the circulation within the head and spinal canal, especially in 
man, is affected by losses of blood differently from the circulation in other parts. 

^ Although the chief effect of excitement of the circulation in anaemia is thus directed 
to the nervous centres, it is by no means confined to them. Other parts, in the imme- 
diate vicinity of the heart, become the seat of increased arterial pulsation and disturb- 
ance. Thus, a painful throbbing is often complained of in the throat, chest, and epigas- 
trium, even when there is little pulse in distant arteries, and the extremities are cold. 
To understand these facts, we must bear in mind that when the arteries are full and 
tense, they oppose their fulness and tension to each contraction of the heart, which re- 
sistance reduces the strength of each pulse in the vicinity of the heart, although it 
continues to propagate it to a distance ; but when the arteries are empty and loose, the 
heart squirts to them the blood in an unresisted jet, the force of which is strong near the 
heart, but extends not to distant arteries. 



164 PROXIMATE ELEMENTS OF DISEASE. 

the passage of tlie blood through the brain. I have met with several 
cases more or less corresponding with the following description. 

A young female becomes anaemic, and after exhibiting various symp- 
toms of feeble general circulation, with headache, drowsiness, and im- 
paired sensorial functions, suddenly becomes worse ; passes into a state 
of stupor with dilated pupils, sometimes varied by slight manifestations 
of delirium, throbbing of the carotids, and partial heat of the head, and 
dies comatose. On opening the head, a small quantity of serum is found 
under the arachnoid and in the ventricles, sometimes with a little lymph 
(in one case there was none). The vascularity of the membranes is 
remarkable, but the vessels most distended are the veins ; and in the 
larger of these, and in the longitudinal sinus, there is a firm coagulum. 
In parts, especially at the torcular Herophili, this coagulum blocks the 
whole sinus, and exhibits a separation of fibrine, portions of which are 
softened down into that opaque purilaginous matter which was long mis- 
taken for pus, but which Mr. Gulliver has shown to be a mere disin- 
tegration of the fibrine which mere stagnation in a warm temperature 
may effect. These have been taken for cases of meningitis. No doubt 
inflammation may supervene in them occasionally, but in two cases that 
have fallen under my notice, there was no adhesion of the arachnoid 
nor deposit upon it, nor any other unequivocal mark of inflammatory 
action, yet the fibrinous and bloody concretions in the veins and sinuses 
were most remarkable for their size and firmness^ (§ 213). 

It appears to me most probable that these aifections originate in the 
encephalic congestion connected with anaemia. Fibrinous concretions 
form on the transverse bands of the sinuses, and increase until they 
considerably obstruct the passage of the blood ; hence the impaired state 
of the cerebral functions, amounting at last to coma. Reaction (§ 16) 
may take place, with determination of blood, and even inflammation, 
and these cause those symptoms of partial excitement that sometimes 
exhibit themselves ; but neither during life, nor on examination after 
death, are the proofs of excitement so prominent as those of obstruction 
and interruption to the cerebral functions. It must be remembered that 
in anaemia the fibrine of the blood is not diminished in the proportion 
of the other animal contents, and it has a greater tendency to coagulate 
than in healthy blood (§ 207). 

269. In anaemia of long duration, the process of nutrition often 
suffers (§ 211), but by no means uniformly. The cornea sometimes 
becomes ulcerated ; probably because, being a non-vascular texture, it 
the more needs a nourishing quality of the plasma. The muscles become 
flabby and attenuated ; wounds and fractures sometimes do not readily 
unite ; and, in some instances, spreading ulcers and sloughy sores form 
spontaneously on the surface. Emaciation is, by no means, a constant 
result of anemia ; and it is not uncommon to see the most pallid sub- 
jects, especially females, retain a considerable amount of fat. Dropsical 
effusion into the cellular texture is a common result of anaemia, when 

' A wax model of tlio sinuses und membranes in one of these cases, is in the museum 
at the University Collej^e. Cruveilliier gives a representation of a similar case, which, 
without sufficient reason, he considers as one of cerebral phlebitis. Andral mentions a 
case of cerebral hemorrhage in connection with anaemia, which was probably of the same 
kind. 



ANEMIA — TREATMENT. 165 

either long continued, or aggravated hj additional causes which disturb 
the circulation (§ 222). The researches of Chossat on the eiFects of 
inanition on animals, are, in some measure, applicable to this subject ; 
for anaemia is the result of deficient food (§ 63). He found that de- 
fective nourishment notably reduced the weight of all the structures of 
the body, except only those' of the nervous system, which were wonder- 
fully little diminished by it. This fact accords with that of the remark- 
ably predominant activity of this system in persons weakened by low 
diet and similar causes, and is well explained by the manner in which 
the vessels supplying the nervous centres monopolize the blood, as indi- 
cated in a preceding paragraph (§ 267). Hence this ascendency of 
nervous function, which was first a temporary result of irregular circu- 
lation, becomes in time permanent from comparative change of structure; 
and the condition which at first might have been obviated by means 
which regulate the flow of blood, assumes the fixedness and intracta- 
bility of structural disease. 

270. Anaemia, in its extreme degrees, may prove fatal suddenly by 
syncope (§ 71), brought on by exertion, or any additional cause of ex- 
haustion ; or, more gradually, by asthenia, or general failure of the 
vital powers, often attended with anasarca; or, by developing tubercu- 
lous (§ 211), or other cachectic diseases, to which the individual may be 
predisposed ; by the singular affection of the head before noticed (§ 267), 
or by slower and less marked changes in the nervous centres, leading to 
paralysis, insanity, amentia, epilepsy. 

[The fundamental and constant character of anaemia, is the diminu- 
tion of the red corpuscles of the blood. Women are more subject to it 
than men, although these may be attacked with spontaneous anaemia at 
all ages. The clot is small, but firm and dense, swims in a large quan- 
tity of colorless serum, and presents on its surface a well-marked buffy 
coat, which, however, differs from the buff of inflammatory blood by a 
gradual termination in the red mass, and not by an abrupt, well-defined 
line. (This is due to the excess of fibrine relatively to the globules.) 
When the red corpuscles are below 80, according to Andral, the bruit 
de soufilet in the arteries is a constant phenomenon. It is often heard 
when their cipher oscillates between 80 and 100, and becomes more 
rare as the physiological mean is approached, and, when it is reached, 
ceases altogether. Whatever other disease, besides anaemia, in which 
this diminution of the red corpuscles exists, we have this phenomenon ; 
in putrid and eruptive fevers, pneumonias, acute articular-rheumatism, 
and in a great variety of chronic diseases. The bruit de soufflet is often 
present in pregnant women, and corresponds with the frequent diminu- 
tion of the red globules in them. 

In spontaneous anaemia, the red corpuscles alone are affected, the 
other sanguine elements remaining intact ; subsequently, however, they 
may become likewise compromised. — C] 

271. Remedial Measures. — Most of the measures useful for the treat- 
ment of anaemia, have been already described as those suitable to restore 
a deficiency of red particles and fibro-albumen (§§ 193, 216). A nourish- 
ing diet, with as much animal food as the digestive powers of the patient 
can master — tonics that best restore the appetite, the powers of diges- 



166 PROXIMATE ELEMENTS OF DISEASE. 

tion and sanguification — the use of means, if necessary, to promote the 
natural excretions (§§ 172, et seq., 191), and an exposure of the patient 
to the pure air and light of heaven, as free and as long as the strength 
and sensibility will bear, form the chief items of the treatment. 

The adaptation of this treatment to particular cases will require much 
discretion, especially in proportioning the food to the faculty of diges- 
tion, and in selecting a tonic that shall not irritate. Where it does not 
disagree, iron, in some of its forms, is unquestionably the best tonic : 
and in many comparative trials, I have found the iodide of iron (in 
solution with syrup) the most speedily efficacious. Besides its tonic 
action, it promotes the secretions more than other combinations of iron, 
and in some way, like other preparations of iodine, increases the free- 
dom of the capillary circulation ; by its use, I have seen females restored 
from extreme pallidity to a rosy hue of health in less than three weeks. 
The sesquioxide, citrate, tartrate, and ammonio-chloride, are more tardy 
in their operation; and the sulphate and sesquichloride are apt to nau- 
seate, or otherwise disagree ; but each is found occasionally useful, and 
so are chalybeate mineral waters. In some cases, any preparation of 
iron causes headache, fever, sickness, or some other symptoms of dis- 
order; and then milder tonics, as columba, or other bitters, with mineral 
acids, or with iodide of potassium, are more suitable at first ; and the 
stronger tonics, with iron, may be given afterwards. In extreme cases, 
as those after excessive losses of blood, I have found it very useful to 
give sulphate of quinia at the same time as the iodide, or some prepara- 
tion of iron. 

The success of the treatment becomes manifest, not only in the return 
of a healthy color to the lips and skin, size to the superficial vessels, and 
strength to the pulse, but also by an improvement in all the functions, 
breath, strength, digestion, &c. It is a curious fact that the venous 
murmurs (§ 263), although diminished, are not so in proportion to the 
apparent return of color to the surface; I have before given reasons for 
considering them to depend on deficiency of albumen, as well as of the 
red particles. This does not accord with the opinion of M. Andral, who 
reckons the vascular murmurs to be a true exponent of the deficiency of 
the red paf tides only ; but this, as a matter of observation, loses weight 
from the erroneous notion which he, in common with Bouillaud, holds 
as to the true seat of these murmurs. Thev believe them to be in the 
carotids only ; I several years since was satisfied, from numerous and 
varied experiments, that Dr. Ogier Ward's opinion, that the loudest 
murmurs are in the veins, is correct. I may add, that they are to be 
accurately investigated only by the flexible ear-tube recommended by 
Dr. Stroud. 

272. Besides these general measures, indicated for all varieties of 
anosmia, particular cases require temporary measures, on the one hand, 
to prevent faintness or excess of weakness (§ 262); on the other, to 
subdue nervous excitement (§ 265)^ and counteract the congestion in the 
head, which we have found to occur (§ 267). Diffusible stimulants, such 
as carbonate of ammonia, valerian, ether, wine, and spirits, are often 
useful as temporary means of obviating the extreme weakness. Symp- 
toms of nervous excitement (§ 26) require nervous Sedatives and nar- 



PARTIAL ANEMIA. 167 

cotics ; such as hydrocyanic acid, hyoscyamus, belladonna, conium, &c. ; 
whilst those of nervous depression indicate the use of such stimulants 
as are found to excite the nervous energies, such as the fetid gums, oil 
of turpentine (especially in enema), strong tea and coffee, cantharides, 
strychnia, electricity, &c. (§§ 130, 155). But, inasmuch as these very 
symptoms seem to depend on the irregular distribution of the little blood 
left in the body, they will be the most effectually relieved by reducing 
this irregularity, by the unremitting maintenance of warmth in the sur- 
face and extremities, aided by occasional friction, rest in the horizontal 
posture, varied with such gentle exercise as the patient can bear; with 
pure air, and the judicious use of tepid or cold sponging, or shower-bath, 
especially directed on the head and spine (§ 124). The symptoms of 
decided cerebral congestion and obstruction have generally been treated 
by antiphlogistic remedies, but with questionable advantage. I have 
found more benefit to result from a mild stimulant and tonic plan, to- 
gether with more or less powerful derivants, purgatives, and saline 
diuretics. Such a plan commonly answers best in the congestive head- 
ache which often troubles anaemic subjects. Depletion is often earnestly 
called for by the patient ; but it should be avoided as much as possible ; 
where absolutely required, from the urgency of the symptoms, cupping 
to the nucha, or leeches to the temples, or, what is more effectual, two 
leeches to the interior of the nostrils, will answer best. Persons who 
have long and severely suffered from anaemia, especially from excessive 
and repeated losses of blood, or from monorrhagia or uterine hemor- 
rhage, or from inordinate lactation, do not lose their nervous symptoms 
in proportion as their blood is restored; and this I would ascribe to the 
structural change which has ensued, as before described (§ 268). The 
treatment necessary in such cases is of a permanent kind, avoiding all 
causes of nervous excitement, and using those various means, medicinal 
and regiminal, which have been formerly recommended as useful in re- 
ducing nervous excitability (§§ 128, 155). Of the medicines serviceable 
in such cases, the metallic tonics are most deserving of mention ; espe- 
cially the valerianate and sulphate of zinc, the nitrate and oxide of silver, 
and the sulphate of copper. 

PARTIAL ANEMIA. 

273. We have the means of studying defect of blood in a part of the 
body in more diversified degrees than defect in the whole ; and the result 
we find to be an impaired state of the functions in every degree, from 
that of mere weakness to that of total suspension and death. Thus 
temporary pressure on the chief artery of a limb soon causes numbness, 
weakness, and reduction of temperature. The same effects result in a 
more marked degree from the ligature of an artery in cases of aneurism, 
and are gradually removed as the supply of blood is restored through 
collateral arteries. In some such cases, the supply of blood is insufficient 
to maintain the vital properties of the part; then chemical affinities pre- 
vail (§ 50), decomposition ensues, and the part becomes gangrenous, and 
dies. A similar result ensues when the arteries of a limb become ob- 
structed by ossification and coagulation, as in senile gangrene. This 



168 PROXIMATE ELEMENTS OF DISEASE. 

event may be produced artificially in animals in forty-eight hours, by 
injecting charcoal powder into the artery of a limb, which totally 
obstructs its capillaries. (Magendie.) It is, most probably, by obstruct- 
ing the circulation, and thus depriving the tissues of an element indis- 
pensable for the maintenance of their life, that inflammation and 
other lesions sometimes terminate in gangrene. 

Softening and wasting of textures are also effects attributable to con- 
tinued defective supply of blood. The former is exemplified in soften- 
ing of the brain and of the heart in connection with ossified arteries ; 
the latter in the wasting of parts subjected to continued pressure. 
Hence partial anaemia is concerned in producing many changes of 
structure arising under various circumstances. Deficient supply to 
secreting organs necessarily impairs the amount and quality of their 
secretions (§ 159). 



SECTION II. 

HYPEREMIA, OR POLYiEMIA, EXCESS OF BLOOD. 

274. Too much blood m the system^ or in a fcirt^ is a most frequent 
element of disease. It implies an undue distension of the vessels which 
contain it ; and a modification of the properties of these, and of the 
heart which propels it, is almost constantly a concomitant of this mor- 
bid condition. The chief vital properties of the heart and vessels are 
irritability and tonicity ; excess (§§ 114, 121) and defect (§§ 116, 123) 
of these form most important elements, which modify the effects of 
excess of blood ; and thus is suggested synthetically a division (long 
recognized as most valuable in practice) into active or sthenic, and 
passive or asthenic hyperaemia ; which distinction is applicable to both 
the general and the partial excess of blood. Another variety of hype- 
rsemia may be distinguished by an altered or perverted action of the 
vessels, which is chiefly applicable to the affection in a part, and 
includes that singular and complex condition, inflammation. A view 
of these important proximate elements of disease (§ 107) is given in the 
following table. It is not meant that the diseased conditions here 
specified are always separate, or that they consist merely of the ele- 
ments here stated ; but these are their most distinguishing parts, and 
most important in regard to treatment. 

{with motion increased = Sthenic 
1 Results. 
— — diminished = Asthenic I 
^emia: \ \ Hemorrhage. 




with motion diminished = Congestion 

— — increased = Determination of blood 

— — partly increased, 

partly diminished = Inflammation. 



Flux. 
Dropsy, &c. 



GENERAL PLETHORA. 169 

SECTION III. 

PLETHORA — GENERAL EXCESS OF BLOOD. 

275. As general ansemia may arise from defective formation or exces- 
sive expenditure of blood, so general plethora may proceed either from 
too much blood being made, or from too little being expended. In 
either case/ the blood accumulates and fills the heart and bloodvessels 
beyond the usual degree. But this implies a certain activity and 
health in the processes of digestion and assimilation, and also a freedom 
from any considerable local disorder. A person with weak digestion, 
rarely becomes plethoric ; and one who suffers from a local ailment, is 
commonly warned by an aggravation of this, before the fulness can 
become general. 

276. The persons who become plethoric are rather those overflowing 
with health, who have a good appetite, and indulge it, without sufficient 
regard to exercise and to the excernent functions ; and whose digestive 
powers are in full activity. The blood-making process is ever on the 
increase, the vessels becoming more and more filled ; and their fulness 
becomes manifest in the red face, distended veins, and full pulse ; the 
heart is excited, and labors with its load, especially on exertion ; hence 
palpitation and short breath may ensue, with somnolency and indisposi- 
tion to exertion ; but these may attract no farther notice than to induce 
the abandonment of exercise. The state of plethora, thus gradually 
induced, may be extreme, without any functions materially failing, and 
yet the subject is on the brink of various maladies. It is well if a great 
secreting organ is first excited under the high pressure, and relieves the 
system through a free discharge, as by mucous or bilious diarrhoea ; or 
some unimportant and convenient set of bloodvessels may give way, as 
in epistaxis, or bleeding piles, &c. ; or one of the great secreting organs 
may fail in its proper function (§§ 170, 254), as the liver or the kid- 
neys ; and a bilious attack, jaundice, or a fit of gout or gravel, is the 
Gonseqaence. Any of these, by establishing a perceptible ailment, 
disturbs the dangerous ease of the plethoric ; and by rendering neces- 
sary a temporary discipline, saves him from the worst results of ple- 
thora — apoplexy, structural diseases of the heart, great vessels, lungs, 
kidneys, or liver. 

277. Besides the causes already noticed, other circumstances may 
induce plethora. The diminution of a natural or habitual excretion or 
loss of blood, the drying up of a long-established sore or issue (§ 270), 
or the removal of a limb ; all of which diminish the expenditure from 
the system, without impairing the blood-making process, often become 
causes of plethora, if no local disorder be excited before the vessels in 
general reach a plethoric tension. 

278. The division of plethora into sthenic and asthenic arises from dif- 
ferent proportions of the strength and irritability of the moving fibre, 



170 PROXIMATE ELEMENTS OF DISEASE. 

which we have noticed as ultimate elements of disease (§§ 110 and 120, 
et seq.). Where the irritability and tone of the heart and arteries are 
in full amount, the increased quantity of blood excites these properties 
to full operation. Short of disease, the functions are active and ener- 
getic in proportion to the quantity of blood which their organs receive ; 
the heart's action and the arterial pulse are strong and regular ; secre- 
tions are abundant, sensibility is keen, contractility powerful and in 
good tone, animal heat is sustained, and the mental and bodily powers 
generally are great and active. But beyond this, plethora tends to 
disease ; the heart's action is over excited ; the pulse is frequent, as 
well as strong and hard ; the face is florid and flushed, and the heat is 
almost feverish ; the capillaries of secreting organs and surfaces are 
variously disordered ; sometimes excited to excessive secretion, some- 
times beyond it, to a state of fulness bordering on hemorrhage or 
inflammation; hence occur bilious attacks, hematemesis, lithic acid 
gravel, strong and acid urine, and various forms of sthenic gout ; the 
sensibility and sensorial powers may be over-excited by the rapid flow, 
or oppressed by the pressure of the blood on the nervous centres. If 
the plethoric state is moderate enough to last for some time without 
immediate disaster, the nutritive function will eventually be affected. 
Some of the superfluous nourishment may become deposited in fat, 
which is another safety-valve to the plethoric ; but even this throws 
an additional burden on the heart and bloodvessels, which are the more 
strained and oppressed, and are among the first of the textures to 
exhibit textural changes, in hypertrophy, valvular disease, aneurism, 
&c. Thus may originate structural disease, from the continued excite- 
ment of sthenic plethora. 

279. Sthenic plethora is that which commonly affects the young, the 
active, and those of sanguine temperament (§ 41). It comprehends a 
rich state of the blood (§ 184), and an active condition of the nutrient 
function (§ 195). Its tendency is to cause general febrile excitement, 
active hemorrhages, fluxes, and inflammations. 

280. In asthenic plethora, there is a want of contractility (§ 116) and 
tone (§ 123) in the moving fibre. The heart and other organs, instead 
of being excited by the augmented quantity of blood, are oppressed by 
its load. The pulse may be full, but it is slow ; sometimes irregular or 
unequal. There is sometimes a tendency to faintness alternating with 
palpitation; physical examination shows the heart to be enlarged by the 
accumulation of its contents, which it cannot expel. The face is purple 
rather than red ; the veins are generally distended ; sometimes the ex- 
tremities are apt to become cold. Other functions are sluggish, and im- 
perfectly or irregularly carried on. The bowels are torpid, the urine 
scanty, high-colored, or turbid, sensibility is blunted, and the mental 
faculties dull, with lethargy or somnolency, the spirits often depressed, 
and the strength reduced. 

281. Asthenic plethora affects especially those weakened by age, ex- 
cesses, or previous disease, and those in whom the excreting organs act 
imperfectly; which imperfect action is a cause, as well as a consequence, 
of plethora. Asthenic plethora tends to produce congestions and pas- 
sive hemorrhages, and fluxes and dropsies ; and if continued, structural 



GENERAL PLETHORA. 171 

changes in some organs, as dilatation of the heart, enlarged liver, vari- 
cose veins, &c. Congestion of the brain, with apoplexy or palsy, head- 
ache, or other symptoms of disturbed function, sometimes is produced ; 
or if there be any organ, the vessels of which, from past or present 
causes (§§ 31, 32), are weak, this organ may be the first to suffer. 

282. The symptoms of asthenic plethora hitherto described, are chiefly 
those of a depressed or oppressed state of the functions. Sometimes, 
however, there arise others, betokening excitement or reaction of an ir- 
regular kind. The pulse becomes quickened, and often irregular ; the 
skin becomes hot or partially perspiring ; sickness and vomiting may 
occur; the tongue becomes much furred, and sometimes brown and dry; 
the excretions are defective, unusually offensive, and often changed in 
appearance ; the complexion becomes dusky, the eyes suffused, the men- 
tal faculties confused or impeded in low delirium or lethargy. This is a 
kind of congestive fever, described by Dr. Barlow as a result of reaction 
from asthenic plethora. It is possible that this description has been 
partly drawn from cases in which, besides asthenic plethora, some mor- 
bid poison (§ 258) has been in operation ; but many of the symptoms 
here named may be fairly traced to a congestive fulness of the blood- 
vessels, with an impaired action of the excreting organs (§§ 70, 171, 
&c.) ; and consequently, with the diseased condition of the blood, which 
we have described to arise from imperfect excretion (§ 248, et seq.). 
The mere stagnation or imperfect motion of the blood will prevent it 
from undergoing properly the process of purification and elimination of 
its decaying materials, through the instrumentality of respiration and 
excretion ; hence it becomes loaded with urea, lithic and lactic acids, 
and other effete materials, which unfit it for its proper uses, and irritate 
and disorder the organs through which it passes. The process of reac- 
tion or febrile excitement, which occurs in cases of asthenic plethora, is 
sometimes more distinctly connected with the condition of the blood, as 
in the case of gout (§ 254), rheumatism (§ 251), and various cutaneous 
diseases, which become developed generally in the atonic or asthenic 
forms. 

[In thirty-one individuals suffering from well-marked plethora, the 
mean of the fibrine was 2.7, which is rather below the healthy standard. 
Plethoric persons are consequently not more liable to inflammatory dis- 
eases than others, and an appeal to clinical experience will sustain this 
assertion. The organic materials of the serum do not offer any remarka- 
ble alteration in proportion or composition in plethora. The blood of 
plethoric persons is very highly colored. On coagulation, the serum 
will be found more or less deeply tinged ; the clot is larger, of moderate 
consistence, and contains a good deal of serum, and is never buffed. If 
the blood has flowed very rapidly from the vein, there is sometimes a 
thin, transparent pellicle on the surface. 

In plethora, all the organic functions are more actively performed. 
There is a remarkable disposition to exaltation in the cerebral functions; 
the emotions are frequent and very mobile, without, however, those ex- 
aggerations and aberrations of sensibility, those nervous predominances, 
which almost constantly occur in ansemia. Plethoric persons are liable 
to certain accidents, as vertigo, dimness of vision, ringing in the ears, 



172 PROXIMATE ELEMENTS OF DISEASE. 

and heats in the head. These symptoms have been usually attributed to 
cerebral congestion, a condition which has, however, never been ascer- 
tained. Andral thinks these phenomena sufficiently accounted for by 
the passage of an increased quantity of red corpuscles through the ves- 
sels of the brain. It is strange that, as we have seen (§ 264), opposite 
conditions of the red corpuscles as regards quantity, produce analogous 
phenomena. Plethora predisposes to hemorrhages. The bruit de 
soufflet never occurs in plethora, as has been erroneously stated. — C] 

283. Remedial Pleasures. — The means already described as useful in 
reducing an excess of red particles (§ 192) and fibrine (§ 214), are also 
applicable to the earlier and simpler states of plethora. In fact, in 
these states, the blood usually does exhibit this excess, for which blood- 
letting, and other evacuants, and abstinence, are the chief remedies. 
The propriety of bloodletting in extreme degrees of plethora, is evinced 
by the extent to which it may be carried without causing faintness. 
Thus Dr. M. Hall found that, from patients with congestive apoplexy, 
from forty to fifty ounces might be drawn without producing syncope ; 
whilst, in the acute inflammations, the tolerance is usually less by about 
ten ounces. The beneficial effects of bloodletting are sometimes imme- 
diately manifest, although they are somewhat contrasted in the two 
varieties of the disease. In the sthenic kind the pulse becomes softer, 
weaker, and less frequent; in the asthenic, it often improves in strength 
and regularity, and sometimes rises to a natural frequency. In simple 
and recent cases of both kinds, a sufficient bloodletting, with due avoid- 
ance of the causes of the plethora (so far as that can be accomplished), 
and the continued use of a little aperient medicine, may complete the 
cure. 

284. But if the plethora have lasted long enough to produce some of 
its ulterior effects (§ 282), bloodletting maybe an insufficient, nay, in some 
instances, it may be an unfit remedy. In both kinds of plethora, medi- 
cines which increase the excretions are generally indicated, and the diet 
must be much restricted ; but the particular mode in which these ends 
are to be accomplished, varies greatly in the two forms which I have 
been careful to distinguish. 

285. In sthenic plethora, not only the blood is in excess, but also the 
irritability and tone of the moving fibre. Here, then, besides removing 
the excess of blood, sedative and relaxing remedies (§§ 115, 122), are 
indicated. Antimonials, salines, digitalis, and hydrocyanic acid, and a 
cool regimen, we have found to answer this purpose ; and these are often 
most useful in the treatment of sthenic plethora. The same remedies, 
with mercury, colchicum, and some others, fulfil also another indication, 
which may be present, to augment excretions defective from an over- 
excited state of the capillary circulation, which borders on hemorrhage 
or inflammation. If any part should especially suffer, local bloodletting 
may be requisite to prevent such a result. 

286. In asthenic plethora of some duration, on the other hand, al- 
though bloodletting relieves them, it does not restore lost tone to the 
over-distciidcd vessels. Tonics (§ 124), and even stimulants (§ 119), 
may be necessary at the very time that blood is drawn ; and there may 



CONGESTION. 173 

long be required such treatment as is calculated to restore the impaired 
functions of digestion and secretion, and to improve the depraved condi- 
tion of the blood (§ 174). In such cases, the continued use of altera- 
tive aperients and diuretics, such as mild mercurials, with rhubarb, 
aloes, or senna, salines, and taraxacum, nitric acid, iodide of potassium, 
&c., may prepare the way for various tonics, such as columba, bark, 
and iron. In such cases, mineral waters, like those of Cheltenham, 
Leamington, and Llandrindod, are often of great service ; first the 
saline, which are aperient and diuretic, and afterwards the chalybeate, 
which, although tonic, usually contain enough saline matter to keep the 
secretions free. Some of the latter class, as the Bath waters, sometimes 
excite torpid and plethoric habits to a critical reaction, by bringing on 
a regular fit of gout (§ 254). 

The diet, which should be very spare in sthenic plethora, must not be 
too much reduced in that of the asthenic kind. The food should be 
simple, but nourishing, and adapted to the power of digestion. Stimu- 
lant drinks are not generally necessary ; but previous habits must be 
considered, and not suddenly reversed. Regular out-door exercise, as 
much as the strength will bear without causing excitement or exhaustion, 
is a most salutary part of the regimen. 



SECTION lY. 

LOCAL HYPEREMIA. EXCESS OF BLOOD IN A PART. 

I. WITH MOTION DIMINISHED — CONGESTION. 

287. The true nature and distinctive characters of congestion, or local 
Jiyperdemia ivitli retarded motion, may be conveniently traced through 
its several causes, all of which agree in fulfilling the conditions here 
given as the definition of congestion, excess of blood in the vessels of 
a part, with diminished motion of that blood (§ 274). We have already 
found that parts of the vessels, and even the heart itself, become con- 
gested in asthenic plethora (§ 281) ; but this is as a part of a more 
general disease. We have now to consider the causes and phenomena 
of congestion of blood in a part, which may occur independently of 
general disease. 

288. Bloodvessels become congested, or unduly distended with blood, 
when their proper elasticity and tone are overcome ; and this may 
happen when an obstruction in the veins prevents the free escape of 
blood from them ; or it may happen from weakness of the coats of the 
vessels themselves, which yield to the pressure of the blood transmitted 
to them. The chief causes of congestion may be classed under these 
two heads: 1. Those of venous obstruction ; and, 2. TJiose of atony 
of the vessels (capillaries and veins). Under these two heads we shall 
notice various cases of congestion, which will explain and practically 
illustrate the subject. In congestion from either of these causes, it is 
obvious that, as the blood accumulates in the part, its motion diminishes ; 



174 PROXIMATE ELEMENTS OF DISEASE. 

for, as the great source of its movement is the force from the heart 
directed through the arteries, if the arteries remain unenlarged, the 
force Tvhich the enlarged capillaries and veins receive, will be reduced 
by being divided in their greater area. 

289 (1). Congestion from venous obstruction. — When the arm is tied 
for venesection, the veins are compressed more than the arteries. Hence 
the veins swell, then the fingers become red, and, after a few minutes, 
purple, and the whole limb is swollen from the congestion of blood in 
its vessels. In like manner, cold applied to the surface of the body 
affects and contracts the veins more promptly than the arteries which lie 
deeper, and the capillaries speedily become congested, as evidenced by 
the purple color of the hands and face after exposure. Cold also im- 
pedes the circulation by increasing the adhesion of the fluid to the walls 
of the tubes, a mere physical operation, pointed out by Poisseuille. 
Congestions are caused in internal organs by an obstruction of the veins 
leading from them. Thus congestion of the brain may be produced by 
a tight cravat (§ 51), or by a tumor pressing on the jugular veins. 
Efforts of straining (§ 64), coughing, holding the breath, and asthmatic 
paroxysms, which impede the flow of blood through the lungs, cause 
congestions in various parts. Disease of the valves of the heart, which 
prevents the blood from passing onwards through it, produces fulness of 
the veins and of the capillaries in both the pulmonic and systemic cir- 
culation. Tubercles in the lungs cause congestion of these organs. 
Obstruction to the transit of blood through the liver causes congestion in 
the abdomen, haemorrhoids, &c. The characteristic of congestion begin- 
ning with the veins is, that the veins as well as the capillaries are dis- 
tended ; this appearance is obvious during life in cases of aneurism or 
other tumor compressing the veins of the neck ; and after death, in the 
full arborescent appearance of the veins in the congested part. Certain 
diseases of the organs of respiration, especially extensive emphysema 
of the lungs, in which the efforts of expiration predominate over those of 
inspiration, cause congestions, not merely by opposing the return of blood 
through the veins into the chest, but also by removing that suction in- 
fluence which naturally much promotes the flow of blood in that direction 
at each inspiration. It has been pointed out by M. Berard {Arch. Gren. 
de Med. Jan. 1830), and by Mr. A. Shaw {Med. Gaz. July, 1842), 
that the circulation in the liver is, in health, much dependent on this 
influence ; and it may be inferred that the diminution of this influence 
by extensive vesicular emphysema will assist in explaining why hepatic 
congestion is so commonly combined with this pulmonary lesion. 

290 (2). Congestion from atony of the vessels. — This comprehends 
a numerous class of cases. In some, the atony of the vessels (§ 123) 
affects the whole system, as in case of extreme debility, adynamic fevers, 
and the sinking which precedes death. The heart then acts feebly and 
without force sufficient to propel the blood through the whole circuit of 
vessels ; these yield from want of tone, and most where they are least 
provided with tonic fibres ; that is, in the capillaries and veins, especially 
of parenchymatous organs, which accordingly become congested. The 



CONGESTION. 175 

blood gravitates chiefly in parts that are lowest in the position of the 
body ; which, in their weak state, yield to the accumulating blood. This 
occurrence of the congestion in undermost parts {hypostatic), is the 
distinctive character of that of weakened vessels. Thus the posterior 
parts of the lungs, intestines, and integuments, are found much con- 
gested. 

291. In other cases, the weakness is local, without affecting the ves- 
sels generally, the weakening cause being applied to some vessels only. 
Over- distension is a common cause of congestive weakness of vessels. 
Thus from long continuance in one position, the lower vessels yield to 
the gravitating force (§ 51) of the blood, and become congested. This 
cause makes the feet swell after standing or walking long, especially in 
warm weather. A continued stooping posture, or lying with the head 
low, may occasion congestion of the brain, with headache, giddiness, 
confused vision, and may prove an exciting cause of apoplexy. Remain- 
ing long in a standing or sitting posture, often causes congestion in the 
hsemorrhoidal veins, liver, uterus, &c. Where the circulation is feeble, 
and the tone of the vessels weak (§ 123), these causes of congestion 
operate more readily and more permanently, than where the circulation 
is vigorous ; yet these congestive affections, the result of weakness, are 
often mistaken for inflammations. Many of the pains and ailments of 
delicate females, are of this nature ; and although temporarily relieved 
by depletory measures, are to be permanently counteracted only by 
tonic means (§ 124), which promote the vigor and equality of the circu- 
lation. 

It must be borne in mind that congestion from mechanical causes, 
when it lasts long, may so weaken the vessels by over-distension, as to 
continue after their original cause has ceased to operate. Thus conges- 
tion of the brain or lungs, induced by a paroxysm of dyspnoea, or cough- 
ing, or by violent straining (§ 64), may not subside with the cessation 
of the effort ; giddiness, headache, pain, dyspnoea, &c., remaining for 
some time. 

292. In considering the operation of cold as a cause of disease, we 
found that it chiefly operates by constricting the vessels of the surface 
and extremities, and thus throwing the blood inwardly, causing internal 
congestions by intropulsion (§ 77). If this exists long, the tone of the 
internal vessels will be impaired, and the congestions will not cease on 
the restoration of warmth to the surface. Thus a permanent congestion 
in the lungs, liver, kidneys, mucous or serous membranes, whichever 
happens to be predisposed, may result ; and this congestion may vari- 
ously disorder the function of the part, or may lay the foundation for 
inflammation. 

293. Malaria (§ 82), and the influences which produce continued and 
exanthematous fevers (§ 93), seem to have the same effect as external 
cold, but it is not so easy to explain how they operate. The cold stage 
of these diseases exhibits, in a high degree, the marks of intropulsive 
congestion ; and it is well known that in ague, the congestive enlarge- 
ments of the liver and spleen are among its most remarkable phenomena 
(§ 191). The congestions remaining during the febrile stages. of fevers, 
seem to be the chief cause of their inflammatory complications. 



176 PROXIMATE ELEMENTS OF DISEASE. 

294. Another cause of congestion is over-excitement of the vessels. 
It is well known that after a part has been inflamed, the vessels often 
remain dilated, but without the signs of inflammation. This is well seen 
in the conjunctiva, the throat, the skin, and in certain ulcers, and might 
be exemplified in some internal organs. The liver and stomach show 
many signs of congestion after the excitement of stimulant drinks (§ bQ), 
But we may, under the microscope, trace the production of congestion 
apart from inflammation. 

When a slight irritant, as a weak infusion of capsicum, is applied to 
the web of a frog, it first causes contraction of the vessels, especially the 
arteries (§ 120) ; then quickly follows enlargement of the arteries and 
other vessels with very rapid motion ; after a while, the vessels gradually 
contract, and return to their natural size. But if the stimulant applica- 
tion be repeated several times, so as to prolong the determination of 
blood into the part, the vessels do not then uniformly contract. The 
arteries indeed shrink, but the capillaries and veins remain congested, 
and thus present completely the condition given in our definition, excess 
of blood with diminished motion (§ 287). This dilated state of the 
capillaries and veins must be chiefly ascribed to their losing tone after 
excitement (§ 123), more than the arteries ; but the process which I have 
been describing, is accompanied by changes also within the vessels; 
numerous pale corpuscles adhere to the sides of the small vessels, and 
contribute to impede the current, and cause congestion by obstruction. 
Whenever the stimulus applied has been strong, this obstruction amounts 
to entire stagnation, and many vessels appear much enlarged, and filled 
with stagnant blood, or rather with an accumulation of red particles 
entangled in the coherent pale globules: For this reason, the vessels 
in which the blood is stagnant are of a deeper red than others, the red 
particles being arrested whilst the liquor sanguinis passes on. 

295. All that has been now described belongs to congestion, and there 
can be little doubt that the intense and deep redness sometimes seen in 
congested parts, is partly made up of vessels in which the blood is abso- 
lutely stagnant. We shall find that a similar congestion and stagnation 
exist also in inflammation, and may be the only change left by it to be 
found after death, where the inflammation has not existed long enough 
to produce its more characteristic results. It is for this reason impossible 
to discern by anatomical characters between recent inflammation and 
some forms of congestion. 

296. Congestion occurs in various organs and surfaces when their 
proper secretions are arrested, or suddenly diminished (§ 167). It is 
difficult to determine whether the congestion is the efi"ect or the cause of 
the defective secretion in the first instance ; and very probably the rela- 
tion is mutual ; at least, this is the most convenient view to take of the 
matter for practical purposes. Thus, means which increase the secretion 
(§ 172), will often remove the congestion ; and those which relieve the 
congestion, generally restore the secretion. There is nothing inexpli- 
cable in this, even on the principles already laid down ; for the free flow 
of a secretion will help to unload and set free the distended bloodvessels ; 
and the means which free those vessels from their congested state, will 



CONGESTION. 177 

restore that freedom of circulation through them, which best ministers 
to the secreting process. 

298. In the former edition of this work, I mentioned some cases of 
congestion which had not then been traced to any of the causes above 
specified, although it was not improbable that farther investigation would 
refer them to some of these causes. Thus, when the blood does not un- 
dergo its proper changes in the lungs (§ 234), its passage through these 
organs is partially impeded, and it accumulates in the right side of the 
heart, and in the venous system generally. Congestions thus form a 
prominent part of the pathology of asphyxia. From the observations 
of Dr. John Reid, it appears that some obstruction also occurs to the 
passage of the blood through the systemic capillaries, as proved by the 
increased pressure in the arteries, indicated by the hsemadynamometer. 

I stated that it remained for future observers to determine whether 
these obstructions are connected with contraction of the vessels (§ 120), 
increased spissitude or cohesion of the blood, or other simply physical 
cause ; or whether they depend on peculiar (vital) attractions and repul- 
sions exerted between the vessels and its blood, which properties are 
supposed by some physiologists to constitute an important element in 
the healthy, as in the morbid phenomena of the capillary circulation.^ 

1 Whatever influence the vital properties of the blood may be supposed to exert in im- 
peding the passage of the blood through the capillaries, I can see no reason for admitting 
that they in any degree contribute to its motion. That the power of the heart, distributed 
by the arteries, is sufl&cient to carry on the circulation, is apparent from several experi- 
ments, of which some performed by my colleague. Dr. Sharpey, are the most convincing. 
A syringe, with a hsemadynamometer to show the amount of pressure used, was adapted 
to the thoracic portion of the aorta of a dog just killed, which vessel had been previously 
tied immediately above the renal arteries, and the vena cava inferior was opened at its 
exit from the diaphragin. Fresh bullock's blood (deprived of its fibrine by whipping and 
straining, to prevent its coagulation) was then injected with a pressure of three and a half 
inches of mercury, and passed out of the vein in a free stream, after having pervaded the double 
capillary system of the intestines and liver. When the pressure was increased to five inches 
mercury, the blood spirted from the vein in a full jet. When the aorta was not tied above 
the renal arteries, but left free, the same pressure was sufficient to drive the blood through 
the extensive ramifications of the lower extremities. On the same instrument being adapted 
to the pulmonary artery, it was found that a pressure of from one and a half to two inches 
of mercury was sufficient to propel the blood through the capillaries of the lungs, so as 
to flow freely from the left auricle or pulmonary veins. 

The amount of force thus used is not greater than that which the hsemadynamometer 
shows the heart commonly to exert in propelling the blood during life, in the systemic 
and pulmonary circulation respectively ; and we thus obtain almost a demonstration, that 
the heart's power, distributed by the arteries, is sufficient for the process of the circula- 
tion. An intelligent reviewer of the former edition of this work, has opposed to this 
inference the case of a foetus without a heart, in which circulation and nutrition seem to 
have been well performed ; but before we can admit the force of such a questionable and 
exceptional fact, it must be proved that there was no compensatory muscular apparatus 
in the large vessels, such as is known to exist and aid the circulation in fishes and insects, 
to the structure of which these monstrosities often in other respects approximate. 

The chief arguments for and against the existence of vital properties of attraction and 
repulsion at sensible distances, have been well stated by Professor Allen Thomson, in the 
article "Circulation," in the Cyclopsedia of Anatomy, to which I would particularly refer 
the student. In addition to these, I would state that in many long and careful microscopic 
examinations of the circulation in the frog's web, variously modified by difi"erent agents, 
I have never witnessed any movement of the blood-particles, which was not plainly refer- 
able to the action of the heart or of vessels. The share which the arteries have in regu- 
lating the flow of blood, through the capillaries and veins, is most evident. When tlie 
arteries increase in size, the flow becomes very rapid and general ; when they diminish, 
the flow is tardy, and even ceases in some capillaries ; and when the arteries contract, so 

12 



178 PROXIMATE ELEMENTS OF DISEASE. 

The researches of my friend, Mr. John Erichsen, {Edin. 3fed. and 
Surg. Journ. Xo. 163), on asphyxia, have satisfactorily settled this ques- 
tion in favor of the first of these alternatives, which was long since sug- 
gested by me (3Ied. Craz. Sept. 1835 and 1838). After having shown 
that analogy is not opposed to the fact of the contraction of the minute 
arteries being excited by the passage of venous blood through them, Mr. 
Erichsen adds : — 

"But we may go a step farther, and prove that it (venous blood) ac- 
tually possesses this power ; causing these vessels to contract distinctly, 
as I have several times observed, on examining, under the microscope, 
the mesentery of rabbits, during and immediately after the process of 
asphyxia. This may be done without much difficulty, as the circulation 
of these animals, when quite young, continues for many minutes after 
the struggles of asphyxia have ceased. On asphyxiating a young rab- 
bit, a portion of whose mesentery had been conveniently fixed under a 
powerful microscope, the following phenomena will be observed to en- 
sue. For about a minute after the struggles of the animal have ceased, 
the circulation appears to be going on with its usual rapidity ; it then 
gradually becomes somewhat slower, the arteries contracting in size, 
containing less blood, and assuming a lighter and more tawny color than 
before ; whilst the veins become congested, and evidently fuller, assum- 
ing, when viewed by transmitted light, a very beautiful crimson hue. 
As the circulation becomes more languid, the arteries continue con- 
tracting, and acquire a lighter color ; the diminution in their size, and 
the difi'erence in the quantity of blood contained in them and in the 

as to permit no blood to pass through them, the blood which still fills the capillaries and 
veins becomes quite stagnant, without a sign of spontaneous moTement. When motion 
begins again, it may always be traced to an artery, which first admits a file of single 
globules, which come few and far between, and in pulses ; afterwards, as the artery en- 
larges, many rush in a continuous rapid stream, supplying proportionate motion to the 
vessels beyond. These observations precisely correspond with those since made by Mr, 
Erichsen, and numerous recent microscopic observers. In the recent work of Mr. Travers, 
on Inflammation, some terms are applied which might seem descriptive of spontaneous 
motion of the blood-corpuscles, such as "pioneering corpuscles," but it is plain that this 
term is used figuratively, for Mr. Travers distinctly traces the motion to the impulse of 
the heart, communicated to the adjoining capillaries. 

Many of the instances of supposed vital motions in the blood, and other organic mole- 
cules, are referable to mere phj'sical causes. Similar movements may be seen, quite as 
animated in appearance, on mixing, under the microscope, two drops of saline solutions 
of different strength or nature ; any insoluble powder in these di'ops moves, as it were, 
spontaneously, and the motion continues until these drops have entirelj^ pervaded each 
other. Still more lively motions are seen on adding any resiuous tincture to water. Simi- 
lar causes operate on blood-molecules, giving them motions which appear to be spontaneous. 
But blood-particles move also from another cause; they are not only carried by the current, 
but they are often changed in shape by it. Being vesicles, they swell or shrink by endos- 
mose and exosmose, on any change in the densitj^ of the liquid in which they are conveyed ; 
and these changes aifect tlieir position and form, their aggregation and separation, in a 
manner which might readily give the idea of their possessing spontaneous motions. 

Although it seems unwarrantable to admit a self-motory power in the blood-particles as 
aidinr/ in the circulation, it is highly probable that changes in them, as well as in the vessels 
wliich convey them, may iirqyede the circulation. Tlic adhesion of the lymph-globules to 
the sides of the vessels, and to each other, and perhaps, the cohesion of the blood-disks, 
are changes likely to produce this effect. We shall find these have a large share in causing 
the obstruction of inflammation ; and, as before mentioned, they probably operate in in- 
tense and long-continued congestion; but Mr. Erichsen's observation disproves their 
operation iu asphyxia. 



CONGESTION — CAUSES. 179 

veins, being most marked. The motion of the blood in the capillaries 
now becomes oscillatory, the whole mass of blood being, at each impulse 
from the heart, slowly propelled forward, and then moving backwards. 
This to and fro motion continues for some time, and then ceases en- 
tirely. On restoring the heart's action by setting up artificial respira- 
tion, an impulse was evidently transmitted from the blood in the arteries 
to that in the capillaries in a pulsatory and jerking manner, which was 
soon communicated to the veins, driving forward the whole mass of glo- 
bules accumulated in them, and gradually becoming more equable and 
powerful until the circulation was completely restored. I have watched 
these phenomena most attentively in the mesenteries of young rabbits, 
and have never observed anything like spontaneous movements in the 
capillaries ; the blood contained in which was invariably most clearly 
and distinctly influenced, solely by the impulses it received from that 
contained in the arteries. Nor have I ever been able to discover any 
obstruction in the vessels in consequence of the adhesion of colorless 
globules to the sides — a phenomenon that I especially watched for, and 
which has by several been supposed to occur. The diminution in the 
diameter of. the smaller arteries, and the proportionate difference be- 
tween them and the neighboring veins, were most evident, and were 
such as could leave no doubt in my mind, as to the important part that 
the contraction of these vessels plays, in giving rise to an obstruction 
to the passage of the blood through them in asphyxia ; in which I have 
no doubt that it is the principal, if not the sole agent. 

These observations correspond perfectly with what I have many times 
observed in the frog's web ; and we may fairly infer that the same ob- 
struction which operates in the systemic circulation, will suffice also in 
the pulmonary. The notion of vital attractions of the blood for the ves- 
sels, or even of the aggregation of the red corpuscles (suggested by an 
imperfect observation of Mr. Wharton Jones), as causing the obstructed 
circulation of asphyxia, is not only superfluous, but untenable; for, were 
the obstruction in the capillaries and veins, the arteries, for a time at least, 
should exhibit distension, which the above description proves not to be 
the case. 

The instances of obstructed pulmonary circulation recorded in Mr. 
Blake's experiments, in which certain saline solutions (of salts of soda, 
silver, &c.), injected into the veins, caused death, by obstructing the pas- 
sage of blood, without coagulating it or arresting the breath, will admit 
of the same explanation 

299. We have considered atony of the small vessels (§ 290) as a chief 
cause of congestion ; and it is so, not only by making them yield and 
become distended by the accumulation of blood, but also by rendering 
them unfit to transmit the force of the current in its proper direction. 
Vessels which have lost their tone, become inelastic and tortuous, and 
the very accumulation of blood in them opposes an increasing obstacle 
to its passage through them. The physical principle to which I now 
refer is not generally understood, and I will illustrate it by some experi- 
ments. 

300. To one of Read's enema syringes, was adapted a tube with two 
arms ; to one arm was fitted a brass tube two feet long, having several 



180 PROXIMATE ELEMENTS OF DISEASE. 

right angles in its course ; to the other arm was tied a portion of rabbit's 
intestine, four feet long, and of caliber (when distended with water) 
double that of the brass tube. The intestine was placed in curves and 
coils, avoiding angles and crossings, which might obliterate the canal. 
The discharging end of both tubes was raised to the same height, that 
of the intestine being kept open by a short tube of metal. The tubes 
were then both filled by successive strokes of the piston ; and when they 
both began to discharge, the quantity received from each in a given 
number of strokes was ascertained. Without giving the details, it may 
be stated that the small metal tube discharged from two to five times 
the quantity discharged by the larger but membranous tube ; the differ- 
ence being greatest when the strokes of the piston were most forcible 
and sudden, by which the intestine, although much swelled at its syringe 
end at each stroke, conveyed comparatively little water. The differ- 
ence was farther increased by raising the discharging ends higher ; and 
when both ends were raised to the height of eight or ten inches, the gut 
ceased to discharge, each stroke only moving the column of water in it, 
but this subsiding again without rising high enough to overflow. On in- 
creasing the force of the stroke, the part of the intestine nearest to the 
syringe burst. 

The experiment was repeated in various ways, of which I will mention 
one, with a metal tube two feet eight inches long, and a bore three- 
eighths of an inch, and a portion of dog's intestine of the same length, 
but when distended, of double the diameter. The metal tube yielded 
three times more liquid than the intestine. 

301. These experiments show that flaccidity and increased length and 
size of the tube afford impediments to the passage of liquid through it ; 
and although the experiments exaggerate the difference between healthy 
and relaxed or congested vessels, yet they really prove that the in- 
creased tortuosity and number of vessels in a congested part, the greater 
mass of their contents, and the atonic flaccidity of their coats, do truly 
form additional obstacles to the passage of the blood through them, al- 
though the amount of these obstacles will vary according to the state of 
the connected circulation. 

These experiments illustrate a principle that is too little considered 
in animal and general physics ; the loss or neutralization of force, hy 
misdirection. The bloodvessels, in their healthy condition, are so con- 
stituted as to make the most of the heart's propulsive power, and trans- 
fer it throughout their whole length ; but when dilated, tortuous, flaccid, 
and otherwise altered, they misdirect and exhaust it (as in the experi- 
ment with the intestine) : it is partly expended in distending and dilat- 
ing the nearer portion, whilst a sufficiency does not remain for the 
onward propulsion of the blood, which therefore stagnates and accumu- 
lates in the congested vessels. We shall have other occasions to revert 
to this principle, which explains many anomalies of unequal circulation. 
It is probably much concerned in keeping up the congestion which has 
been for some time established by other causes ; and it may be the means 
of perverting an increased flow through the arteries, which otherwise 
might sweep away the congested blood — into that mixture of opposing 
forces, which exists in inflammation. This conversion of congestion into 



CONGESTION — SYMPTOMS AND EFFECTS. 181 

inflammation frequently occurs in circumstances corresponding with this 
description. 



THE SYMPTOMS AND EFFECTS OF CONGESTION. 

1. Effects in the congested part. 

303. TVhen the arm is tied for venesection, the parts beyond the liga- 
ture become congested. At first, the hand feels rather warmer than 
usual, and somewhat tender, from the distension of its vessels with warm 
blood; but it soon becomes numb, cold, and weak, showing that the want 
of circulation lowers its vital properties. In like manner, simple con- 
gestion generally impairs the vital properties of internal organs, although 
the undue distension of their textures by the increased mass of blood, 
may cause partial excitement. Natural contractility and sensibility are 
lowered, whilst pain (§ 126), spasm (§ 114), and morbid sympathies 
(§ 149), are often produced, but in a manner much less distinct and 
constant than in inflammation or determination of blood. Thus conges- 
tion of the liver is sometimes accompanied by pain or tenderness ; some- 
times it is without either. Congestion of the stomach sometimes causes 
gastralgia, na.usea, and vomiting, and altered appetite ; but these symp- 
toms are often absent when the amount of disease of the liver or heart 
and the subsequent occurrence of haematemesis, leave no doubt that the 
stomach was congested. The same remark is applicable to the kidneys, 
the uterus, the brain, and other organs. We often see the tonsils and 
uvula congested and enlarged, without pain or soreness. Impaired 
nervous and muscular function is a more constant concomitant than 
pain, or any symptom of irritation. 

304. The natural secretions of congested parts are sometimes at first 
augmented, as in congestion of the conjunctiva and Schneiderian mem- 
brane from cold ; but more generally they are diminished, as in bronchial 
congestion (dry catarrh), and congestion of the liver, kidneys, &c. But 
%"ery commonly, congestion leads to an increased transudation from the 
whole distended capillaries, causing effusions of the watery and saline 
part of the blood, more or less impregnated with albumen, and some- 
times even with fibrine, as exemplified in the fluids of fluxes and dropsies. 

The process by which this is the effect of congestion or secretion, 
seems to be chiefly a physical one. The. portions of the vascular appa- 
ratus most concerned in supplying the secreting structure, seem to be 
the middle parts of the capillaries, which are often so turned or convo- 
luted, as to receive the most direct force of the current from the arteries. 
But when congested, the vessels leading to the middle capillaries become 
yielding, loose, and tortuous, and the force is much expended in dilating 
these before it can reach the portions which supply the secreting surface, 
or cells ;^ these portions are in the condition of the distant end of the 

' It may seem that this is taking too mechanical a view of the process of secretion: but 
be it remembered that I do not ascribe secretion Tvholly to mechanical agency, bnt only 
assert what is known to be a fact, that due force of the capillary cii'culation is a condition 
favorable to this process. In lately inspecting the beautifully injected preparations of Mr. 



182 PROXIMATE ELEMENTS OF DISEASE. 

intestine in the experiment above related (§ 300), not duly receiving the 
force of the current. Thus the more essential effect of congestion is to 
impair the natural secretion. 

305. But the distension of the congested capillaries sometimes leads 
to a general exhalation of their more watery contents, which, mingling 
with the natural secretion, render it w^atery and sometimes albuminous. 
Thus congestion of the bronchi sometimes ends with bronchorrhoea. 
Congestion of the intestines causes diarrhoea ; congestion of the uterus, 
leucorrhoea ; congestion of the kidneys, watery and sometimes albumi- 
nous urine ; congestion of the lungs and pleura, hydrothorax : of the 
heart, hydropericardium ; of the abdomen, ascites, &c. 

306. The element of congestion chiefly concerned in the production 
of these effusions, is extreme distension of the vessels. They are less 
commonly found, therefore, in mere hypostatic or gravitative congestions 
(§ 291), in which the distension is inconsiderable, but they more result 
from congestions from venous obstruction (§ 289), especially when these 
occur suddenly, whilst the vigor of the circulation is not impaired. 
Thus the congestions connected with diseased heart or liver, produced 
by acute attacks or other additional causes of obstruction, especially in 
plethoric subjects, if not soon removed, are pretty sure to end with drop- 
sy, flux, hemorrhage, or inflammation. The circumstances that deter- 
mine which of these results shall ensue, will be considered when we come 
to these proximate elements of disease ; but it may be mentioned that 
besides distension of the vessels, the condition of the blood considerably 
influences the result; a watery state promoting the transudation (§ 222), 
whilst a highly albuminous and fibrinous blood (§ 195) requires more 
pressure to make its watery parts pass through the coats of the con- 
gested vessels. 

307. The same circumstances determine the character of the effused 
fluid. Where the blood is poor, the watery parts easily pass from con- 
gested vessels, even without much distension, and contain but little 
albumen. But if the blood abounds in the proteine compounds, more 
pressure is required before much effusion takes place ; and then, when 
the pressure is great, the fluid effused often contains, not only albumen 
in large proportion, but self-coagulating fibrine also (§ 211). Thus, I 
have seen the fluid of the pleura and pericardium, in rapidly fatal ob- 
structive mitral disease, coagulate spontaneously into a fibrinous crassa- 
mentum, when removed from the dead body. The gelatinous masses of 
lymph often found in the peritoneal sac of the abdomen and pelvis in 
ascites from contracted liver, I have no hesitation in referring to the 
same origin.^ 

308. Fluxes arising from congestion of high tension exhibit an un- 
usual amount of animal matter of an albuminous or mucous kind, as 

Dalrymple, and, Mr. Toyiibee, I was particulai-ly struck with the distribution of the capilla- 
ries of secretinj^ surfaces, sucl) as mucous and synovial membranes. These capillaries run 
pretty straight from the minute arteries, and end in loops and ampullar on the surface, the 
returning vessels passing l)ack as straiglitly. The physical effect of this provision is ob- 
viously to direct tlie chief force on the terminal loops which supply the secreting surface. 
1 This is the true pathology of the "fibrinous dropsies" of Vogel and other German 
writers. 



CONGESTION — SYMPTOMS AND EFFECTS. 183 

instanced in bronchorrhcea, mucous diarrhoea, and leucorrhoea. I have 
been induced to suppose that the polypous concretions and pseudo-mem- 
branous films occasionally effused on mucous surfaces, may result from 
long-continued congestion, with a highly fibrinous state of the blood 
(§ 195). I have seen these evacuated from the air-tubes, in one case, 
and in several others from the intestines, from time to time, for months, 
and even years, without symptoms of inflammation, but under circum- 
stances rendering it probable that congestion was present. Extensive 
disease of the heart existed in the former case, and disease of the liver 
or amenorrhoea in the latter. 

309. I have, for several years, referred albuminous urine (§ 249) to 
congestion of the kidney ; and this vicAV has been lately confirmed by 
some experiments by Mr. G. Robinson. The following considerations 
led me to entertain this opinion : 1. The urine often becomes albu- 
minous, during great embarrassment of the circulation in cases of 
organic disease of the heart or lungs {§ 289), when the kidneys are 
otherwise healthy. 2. I have in many instances, observed temporary 
albuminuria during the cold stage of ague, and the congestive stage of 
eruptive fevers. 3. In granular degeneration of the kidney, the amount 
of albumen in the urine is augmented by circumstances causing conges- 
tion of the kidney, and is reduced by remedies suited to remove this. 4. 
The most common form of Bright's disease of the kidney in its earliest 
stage, presents the appearance of a highly congested structure, and is 
excited by causes calculated to produce congestion, such as frequent 
irritation of the kidneys by stimulating liquors — congestion from ex- 
hausted tone (§ 294) ; continued exposure to cold, especially after the 
kidneys have been thus excited — congestion from intropulsion (§ 292) ; 
scarlatina probably operates as the two last combined. 5. The albu- 
men in the urine abounds most in the congestive (first) stage of Bright's 
disease — the vessels becoming more or less obstructed in the progress 
of the disease, by deposit of fibrine with granular cells in the tubules, 
and in some instances around them, which deposit, at the same time, 
perpetuates some degree of congestion, whilst it supersedes the proper 
secreting structure.^ 

1 The secreting structure is partly diminished in another way also. The granular de- 
posit presses not only on the bloodvessels, but on the uriniferous tubuli also ; and wherever 
it totally obstructs them, their office ceases. These tubuli becoming distended, form the 
serous cysts, so commonly found in granular kidneys, and sometimes in those which are 
not granular. But these cysts contain serum, or a gelatinous fluid, with little or no urine ; 
and this fact has been urged against the notion that they are dilated uriniferous tubes. 
The explanation, however, is not difficult. The secreting function of the kidney lies in 
nucleated cells lining the tubuli (Bowman) ; growing, filling, and bursting, as these cells 
do, by imbibition from adjoining vessels, this process, which is that of secretion, must be 
stopped when the cells are themselves pressed on by an accumulation of their own secretion 
which cannot escape ; but serous exhalation from the bloodvessels still goes on, displacing 
by endosmosis the urine, and at last distending the duct into a cyst. The same explanation 
will appl}^ to the serous cysts of the liver. This view explains how retention of virine or 
bile, may lead to the suppression of the secreting power. 

The above note, which appeared in the first edition, represents the view which still ap- 
pears to me the true one of the origin of cysts in the kidney, and it corresponds witli the 
opinion advanced during the present year by Dr. George Johnson, in a paper read to the 
Medico-Chirurgical Society. At the same meeting, a communication from Mr. Simon re- 
presented the cysts as enlarged epithelial cells, developed in consequence of the oblitera- 
tion of many of the tubes. 



184 PROXIMATE ELEMENTS OF DISEASE. 

310. From what has just been stated, it may be inferred that conges- 
tion, if continued, may affect the nutrition and structure of textures. 
It generally tends to cause an increased deposit in them, constituting 
a variety of hypertrophy^ or overflow of plastic matter. Thus, with 
diseases of the heart which cause congestion, there is an increase in the 
weight of viscera generally, more particularly of the lungs and liver. 
(Clendinning.) The enlargement of the liver and the spleen from long 
attacks of intermittent fever (called ague-cake), may probably be re- 
ferred to the congestion which this disease is known to induce (§ 293). 
I have known a similar enlargement of these organs to ensue, after long- 
continued exposure to cold and damp (§§ 77, 292). 

311. But the hypertrophy resulting from congestion is probably not 
of a uniform kind, comprising equal growth of all the textures ; but, 
arising from an effusion of lymph from the most congested vessels, it is 
an intervascular deposit — at first mottling and exaggerating the appear- 
ance of the natural structure, as seen in the nutmeg liver and in the 
early soft stage of granular degeneration of the kidney — afterwards 
contracting and compressing the natural structui'e, and ultimately caus- 
ing its condensation and atrophy, whilst the new deposit itself forms a 
granular or nodulated texture of low vitality (§ 211). 

312. Such I believe to be the nature and origin of some varieties of 
cirrhosis of the liver, and granular degeneration of the kidney. The 
variations which these structural diseases present, may often be traced 
to their degree of advancement, or to the extent to which they involve 
the structures ; and an argument in favor of their origin in congestion, 
may be found in the fact that they are commonly more advanced and 
extensive in the most dependent parts of the organs, and the lower mar- 
gins of the liver, where congestion is most promoted (§ 290). It is 
highly probable, also, that these plastic products of congestion are, in 
some cases, more or less developed and farther modified by determina- 
tion of blood or inflammation, and by the composition of the blood 
itself. 

Thus, in some instances, the deposit exhibits more of a fibrous or 
closely compacted granular character, firmly adherent to the investing 
membrane, which is more the character of an inflammatory product. In 
others the deposit is loosely granular, or in irregular cells, often with a 
predominance of fat-globules, with little cohesion ; indicative of a de- 
generative condition of the plasma, such as is found in scrofulous or 
cachectic states. 

Long-continued congestion in the lungs may cause hypertrophy of 
the intervesicular and interlobular texture, and in some cases, partial 
consolidation of the vesicular structure itself. Such changes are fre- 
quently met with in connection with long standing disease of the heart, 
and abound most in the posterior parts of the lungs, and near their 
roots, the most vascular parts. In the membranes of the brain, and in 
the capsules of the heart, liver, and spleen, opaque thickening is often 
seen along the course of the bloodvessels, especially of the veins ; ap- 
parently the result of the overflow of nutritive matter from these vessels. 



CONGESTION — REMEDIES. 185 



2. Effects of local Congestion on the System. 

When a congestion is extensive, it has constitutional as well as local 
effects. In proportion as blood accumulates in excess in a part, it leaves 
the rest of the body with less than its proper share, and the limbs and 
surface generally may show various symptoms of weak circulation and 
w^ant of blood. Thus, with considerable congestion of the liver, lungs, 
or brain, the surface is pallid and chilly, the pulse weak and small, the 
extremities cold, there is a peculiar feeling of languor or weariness, 
and all the functions are indifferently performed. Such an effect on 
the system may be produced artificially, by applying a tight bandage 
around both thighs at once, or even both arms in a weak person ; the 
limbs beyond the ligature become congested (§ 289), leaving a deficiency 
of blood in the rest of the body. The extreme of this condition is the 
cold fit of an ague, in which extensive internal congestions are the most 
essential pathological change (§ 293). As in this example, so with 
other extensive congestions, more especially if suddenly induced, as by 
cold (§ 294), a reaction may ensue (§ 16), causing quickened pulse and 
circulation, hot skin, and other phenomena of fever. Where this reac- 
tion is vigorous, it may fulfil its object in sweeping back the congested 
blood into the circulation, and thus restoring the balance. Where the re- 
action is weak, it will fail to remove the congestion, but constitutes a low 
feverish excitement, often remittent in type, with depraved functions, foul 
tongue, impaired excretions, restless nights, &c., which may proceed 
for an indefinite period, until a critical evacuation by sweat, urine, or 
diarrhoea (§ 171) terminates it, and with it sometimes the congestion 
that has induced it. In other cases there is no symptom of reaction ; 
but the congestion, if extensive, is not without its injurious constitu- 
tional effects; the stagnant blood, unpurified and unrenovated, becomes 
gradually injured in its C(^mposition ; and not only unfit for farther use 
in the economy, but a source of contamination to the rest of the blood 
(§ 191), and a cause of cachexia in the system at large. Extreme re- 
sults of this kind are presented in the slow operation of malaria in 
those continually exposed to their influence (§ 85), in the low apyrexial 
congestions which precede typhoid pneumonia; but slighter and commoner 
examples are frequently observed in those whose general health suffers 
from continued congestion, and in whom the loaded and vitiated excre- 
tions, which, even without fever, continue to be thrown off, afford evidence 
of a process of decay in the animal fluids, which is the necessary con- 
sequence of their imperfect purification. 



REMEDIES FOR CONGESTION. 

313. The most important means in the removal of congestion are 
those which contribute to the removal of their causes. Thus the loosen- 
ing of a ligature, or the reduction of a tumor, compressing veins ; the 
moderating the inordinate and inefiicient action of a diseased heart ; 
the restoration of the secretion of the liver (§ 172), will severally tend 



186 PROXIMATE ELEMENTS OF DISEASE. 

to diminish the congestions resulting from these different causes of 
venous obstruction. 

314. So, also, in the treatment of congestion from atony or weakness 
of the capillaries, it is important to remove the circumstances which 
have caused this atony. In many cases it is over-distension from gra- 
vitation (§ 296) ; here change of posture gives relief. Thus, in con- 
gestive fevers, and other states of continued weakness, it is useful to 
change from time to time the position of the patient from supine to 
prone, or lying on either side. With congestion of the head, this part 
should be supported high. The recumbent posture gives much relief 
to congested hsemorrhoidal or uterine vessels ; as we see it reduce the 
swelling of varicose limbs. 

Pressure is sometimes a remedy for congestion, by supporting the 
weak vessels, and promoting their contraction. This forms a chief 
part of the useful operation of bandages,' adhesive plasters, and even of 
poultices, in various external congestions. It probably might be more 
extensively applied to these, and even to some internal congestions, in 
the modes suggested by Dr. Arnott, by mercury, or by the soft slack 
air-cushion pad. 

Friction is a modification of pressure especially suitable to some forms 
of congestion, being calculated to give the motion that is defective, as 
well as to support the weak vessels. It is obviously useful in external 
congestions from cold; and sometimes in visceral congestions, as those 
of the liver and abdomen generally. Exercise operates somewhat in the 
same way. 

315. Another class of remedies for congestion comprehends those 
which promote the contraction of the dilated vessels by augmenting 
theiv contractility or tone (§ 124). In this way, astringents and cold 
operate ; as in the use of solutions of alum, sulphates of zinc or copper, 
acetates of zinc or lead, and infusion or decoction of oak bark, catechu, 
kino, nutgalls, &c., in various congestions, particularly of the conjunc- 
tiva, throat, rectum, and vagina. The most obvious part of the action 
of bark, quinia, and arsenic, in the cure of ague, is in their reducing 
the great visceral congestions, which form their most remarkable, and 
perhaps their most important, pathological element. 

316. The utility of astringents in congestion is limited by the fact, 
visible under the microscope, that they commonly contract the arteries 
more in proportion than the capillaries and veins, which are most dis- 
tended. Hence they may still farther impair the motion of the blood, 
and increase the congestion. A reaction, however, sometimes occurs, 
which converts the operation of the astringent into that of a stimulant, 
which is another kind of remedy for congestion. The same remark is 
applicable to cold; and even more so, inasmuch as it also causes a phy- 
sical obstruction to the flow of blood, in the manner formerly described 
(§ 296). 

Stimulants sometimes arc remarkably effectual in removing conges- 
tions. Thus dihited spirit lotion to a congested conjunctiva, capsicum 
gargle to a congested throat, a stimulating wash or ointment to a pur- 
ple sore or surface, will often signally reduce the congestion. Other 
congestions are removed by exciting the circulation generally; a stimu- 



COXGESTION — REMEDIES. 187 

lant draught, or even one of any hot liquid, relieves the pulmonary con- 
gestion which has induced a fit of asthma; a congestive headache is 
sometimes mitigated by similar means. Well-regulated exercise tends 
to disperse congestions in various parts. Various agents, which specific- 
ally excite particular organs or parts (§ 173), are often useful in remov- 
ing congestions from them. Thus mercury is, in some cases, a remedy 
for a congested liver; some diuretics, as digitalis and cantharides, for 
congested kidneys ; squill, benzoin, and other expectorants, for bron- 
chial congestion. 

317. The influence of stimulants on congestion may be illustrated by 
the microscope. A solution of capsicum applied to a frog's web, con- 
gested after previous irritation, causes an enlargement of the arteries, 
and an increased flow of blood to and through the congested vessels. 
This flow restores motion where it was deficient, sweeps away the accu- 
mulated blood, and, in some instances, causes the vessels to contract 
afterwards to their natural size; so that the congestion is completely 
removed; in that case, the cure is complete. In other instances, how- 
ever, the stimulants fail to clear the congested vessels ; the enlarged 
arteries pour in more blood ; but this, not overcoming the obstruction, 
increases the hyper^emia, and, as we shall afterwards see, may convert 
it into inflammation. Thus it appears that stimulants, as well as astrin- 
gents, although occasionally proving remedies for congestion, sometimes 
tend to increase it ; and this they are most likely to do when the con- 
gestion is extensive, or of long continuance, or when its causes are still 
in operation. 

318. Under such circumstances, congestion is better relieved by an- 
other class of remedies, depletion, and various evacuants. Bloodletting 
by puncture or incision in the congested parts, enables the distended ves- 
sels to unload themselves, and they may recover their size ; and the 
utility of this expedient is shown in scarifications of congested conjunc- 
tiva and tonsils, and leeches to a congested os uteri. But the blood is 
more usually drawn from the vicinity of the congested part, as by cup- 
ping, or leeches on the chest or side for congested lungs or liver ;^ to 
the sacrum for congested uterus ; or leeches to the anus for congested 
intestines. Or, without actually shedding the blood, it may be drawn 
away from the congested part by derivation, that is, by agents, which 
cause determination of blood or congestion in other parts; as dry cup- 
ping, mustard poultices, and other stimulating applications to the sur- 
face, and by purgatives and other evacuants from the interior. A still 
more powerful agency of the class of derivants is that of removing 
atmospheric pressure from a limb by inclosing it in an air-tight vessel, 
and partially exhausting the air. This was invented by Dr. Arnott, 
and has been lately employed by Sir James Murray and several French 
practitioners. 

. These act by inducing determination of blood, or even inflammation 

^ It is remarkable how quickly congestions may be reduced bj these means. I have 
known a congested liver, which reached from the umbilicus to the fourth right rib (as 
traced by percussion), reduced in twelve hours to its normal dimensions by cupping and 
free purging. Piorry describes a still more speedy reduction of the liver in ague, by the 
influence of the sulphate of quinia. 



188 PROXIMATE ELEMENTS OF DISEASE. 

in another part, and thereby drawing away blood from the congested 
parts. Some means, however, may be employed, which prevent or re- 
move congestion by damming up the blood in other parts, and thus in- 
ducing a counter-congestion. It has long been practised with success, 
to stop a fit of ague by applying a tourniquet to the thigh ; and Dr. 
Buckler, of Baltimore, following a popular practice of a similar kind, 
has called the attention of the profession to the general utility of the 
remedial measures which he terms hdemotase ; which consists in the 
temporary application of ligatures to one or more limbs, which are 
thereby so much congested, that there is not blood left in the circulation 
sufficient to supply the congested vessels, and these, relieved of pressure, 
may contract and expel the accumulated blood. I have employed this 
plan in several cases in which temporary congestions were produced in 
the lungs and liver, and sometimes with a very remarkable preventive 
effect ; but it has little influence on congestions which have long been 
formed, and acts chiefly on the distribution of blood in the larger blood- 
vessels. 

319. The operation of several of the foregoing agents, in combina- 
tion or succession, is generally more effectual than that of single ones 
in the cure of congestions. Thus congestion of the liver may resist the 
action of mercury, and may even be aggravated by it (§ 204), until the 
vascular distension has been partially reduced by local bloodletting or 
derivants ; then the mercury, by increasing the secretion, reduces the 
remaining congestion. Congestion of the kidneys is augmented rather 
than diminished by diuretics, which then fail to increase the secretion of 
urine, but may only render it more albuminous (§ 304). But after some 
relief has been given by cupping to the loins, and hydragogue purgatives 
and diaphoretics, then some diuretics, particularly digitalis and cantha- 
rides, cause a freer flow of urine with less albumen. The same point 
might be farther exemplified ; but it is unnecessary to multiply instances. 

320. The cause of congestion being, in many instances, atony of the 
vessels (§ 290), it may often be counteracted by circumstances which 
augment the tone of the vessels, locally or generally. Thus cold, as- 
tringent, or, occasionally, stimulant applications, by bracing the fibres 
and invigorating the circulation in a part (§ 124), render it less liable 
to congestion from disease ; and general tonic measures operate in a 
similar way on the whole system. The efficacy of bark and arsenic in 
preventing, as well as in removing the internal congestions of ague, 
probably depends on their power of augmenting the tone of the vessels, 
of these parts (§ 315), so that they no longer yield to the distensive 
accumulation of blood within them. A similar virtue seems to be pos- 
sessed, in some degree, by iodine and its preparations, especially the 
iodide of potassium ; under the use of which the disposition to local con- 
gestions is diminished, and those formed are sometimes dispersed, as 
exemplified by the external use of iodine in lepra and other congestions 
of the skin, and of iodide of potassium in congestive headache. Mine- 
ral acids and other tonics have a like effect in cases of general weakness. 
The treatment calculated to remove the results of congestion will be 
considered under the subjects, Hemorrhage, Flux, Dropsy, and In- 
flammation. 



DETERMINATION OF BLOOD. 189 

SECTION Y. 

LOCAL HYPEREMIA.— EXCESS OF BLOOD IN A PART. 
II. WITH MOTION INCREASED — DETERMINATION OF BLOOD. 

321. Numerous examples of this kind of active hypersemia are pre- 
sented in health as well as in disease. The face and neck in blush- 
ing, the uterus and breasts at the periods of gestation and lactation, the 
gums during the process of dentition, the antlers of the stag at the sea- 
son of their development, furnish instances of local determination of 
blood occurring in health. The increased number and size of the blood- 
vessels, manifest by the vascular redness in these cases, show the In- 
creased quantity of blood in the part ; and the stronger pulsation of the 
arteries leading to the part indicates the augmented motion of that 
blood (§274). 

322. In disease, we meet with many examples. Determination to the 
head is one familiarly known ; and it affords the opportunity of display- 
ing one of the characteristics of determination, in the enlargement and 
throbbing of the carotid arteries. I have witnessed this phenomenon in 
a great variety of cases. One patient was subject to attacks of determina- 
tion of blood, which caused him so much suffering and loss of moral 
control, that he cut his throat to destroy his life. When recovering 
from the wound, attacks sometimes came on; first, with beating of the 
carotids, then flushing of the face and head, suffusion of the eyes, and 
sensations of distraction in the head. In the slighter attacks, these 
symptoms would all pass away in a minute or two. I have, in several 
cases, observed the same symptoms usher in the paroxysms of mania. 
Fits of epilepsy and convulsive hysteria are immediately preceded by 
throbbing of the carotids, which shows that determination of blood is 
the proximate cause of the paroxysm. Drs. Darwin and Parry relate 
cases in which convulsive fits w^ere prevented by pressure on one of the 
carotids ; and I have practised this expedient with success in several in- 
stances. Many of the epileptic patients whom I have questioned have 
stated that the fit is always preceded by palpitation, w^hich, for reasons 
before explained (§ 266), sometimes peculiarly determines blood to the 
head. But without the patient being conscious of palpitation, there 
may be determination of blood to the head ; and in numerous oi)serva- 
tions, I have found this to be so commonly present, that I believe it to 
be the common immediate cause of the sudden paroxysms of various 
kinds of disorder which affect the nervous centres. Infantile and puer- 
peral convulsions are probably to be included in this remark, although 
they may be connected with very different conditions of the vascular 
system in point of fulness, and are promoted by an imperfectly purified 
condition of the blood itself (§ 249). 

324. But the most common cases of determination of blood are those 
caused by the application of stimuli. Thus heat causes a flow of blood 
to the surface ; snuff, to the nose and eyes ; spices in the mouth, to the 



190 PROXIMATE ELEMENTS OF DISEASE. 

salivary glands ; food in the stomach, to its secernent vessels ; purgatives 
to the vessels of the intestines, and those of glands connected with them ; 
diuretics, to those of the kidneys, &c. &c. In fact, in the operation of 
most medicines, there is an increased flow of blood to particular organs 
or surfaces; and there are few diseases unconnected with local determi- 
nation of blood. We shall find hereafter that it occurs in inflammation 
as a part of that complex process ; but Dr. Parry, was wrong in suppos- 
ing that inflammation consisted in this alone. 

325. Now, what is the physical cause of determination of blood ? In 
some cases, increased action of the heart (§ 112) may propel the blood 
with unusual force and quantity to the arteries in its immediate vicinity ; 
more particularly when there is little blood in the system, and that little 
accumulates chiefly at and near the heart, as in cases of anaemia (§ 266), 
or in the commencing reaction after great congestion of internal organs 
as in the beginning of the hot stage of fevers; and thus determination 
of blood to the lungs and bronchi, the neck, and head, is a common re- 
sult of inordinate action of the heart. But in many of the examples 
above cited (§§ 323, 324), local determination takes place without any 
increase of the heart's action, and must therefore be due to another 
cause. 

Is such determination of blood caused by increased action of the ar- 
teries ? The only active property which we know these vessels to pos- 
sess is that of slow or tonic contraction (§ 120) ; and such contraction 
of arteries leading to a part, would diminish instead of increasing the 
motion and quantity of blood proceeding to the part (§ 294). 

326. We may affirm, from direct observation as well as from reason- 
ing, that determination of blood is caused by enlargement of the arteries ; 
and this enlargement is the efl*ect of the pressure of the arterial disten- 
sion from behind acting on a tube which has lost some of its contractile 
power (§ 120). The tonicity of the arteries makes them naturally resist 
the distending influence of the mass of blood pumped into them by the 
heart ; but if the tonicity be impaired in any artery, that of other ar- 
teries forces into it the blood in augmented quantity, by which it is 
dilated, and becomes an enlarged channel for the transmission of more 
blood and more force (§ 323). If the artery be thus enlarged, the ca- 
pillaries and veins leading from it will be also enlarged, and will share 
the increase of blood and motion thus supplied to them (§ 298, note). We 
find the proof of the enlargement and distension of arteries leading to 
an inflamed or irritated part in their increased and harder pulse ; the 
coats of the vessels being stretched to tightness, the pulse is no longer 
softened by the usual elastic spring. 

So, too, in the frog's web gently irritated by an aromatic water we 
see the arteries become enlarged, supplying a larger and more impul- 
sive flow of Ijlood to the capillaries and veins, which all become enlarged 
also ; and the whole vascular plexus, including vessels which before 
scarcely admitted red particles, then become the channels of a much 
increased current. This is determination of blood. ^ 

' As these phenomena liave not been distinctly described by observers apart from the 
fartli or effects resulting from over-irritation, which leads to obstruction and inflammation, 
I will state sliortly some results of many observations on the circulation of a frog's web, 
under the influence of moderate stimuli applied to it. These observations were made in 



DETEEMINATION OF BLOOD, 



191 



It has been objected that I assume enlargement of vessels to be the 
cause both of increased motion (in determination), and diminished motion 



the summer of 1841, and some of them are mentioned in my Gulstonian Lectures, pub- 
lished in the Medical Gazette of July, 1841. 

The arteries may be distinguished from the veins in the frog's web, not only by the 
direction of their current and its greater rapidity and transparency, but also by a series 
of lines along their course, marking the size to which they have been distended at some 
previous time. (See A, Fig. 1.) These lines or channellings are most distinct, and are 
more remote from the artery at its angles or bifurcations. They are to be seen at some 
points along the veins, but much less distinctly. Now these lines are in themselves proofs 
of the varying distension of the arteries, and they also furnish the means of measuring 
this varying distention. 



Fio;. 4. 



Fio:. 5. 





When a weak infusion of capsicum is applied by a camel-hair pencil to the web, there 
is a momentary retardation of the current in the veins, and the artery distinctly shrinks 
in size. But in a few seconds the reverse takes place ; the artery swells to beyond its for- 
mer size, and reaches the outmost line of its channel ; the flow of blood through it is too 
rapid to be distinguished, and all the capillaries present a scene of busy motion ; in some, 
the particles passing in numbers and speed greater than the eye can appreciate ; in others 
before invisible, single files force their way in more deliberate, but continuous motion ; 
whilst in the veins the movement is again more rapid. This motion soon begins to flag, 
and becomes remittent or oscillatory in some capillaries ; and it is seen that the arteries 
have already begun to shrink in size, and the channelled lines which they had reached re- 
appear. Sometimes, in shrinking, the artery assumes for a time a more tortuous shape 
than before (as A, in Fig. 2) ; so that its walls cease to be parallel with the lines, which 
seem to show that it contracts in diameter, before its length is proportionally reduced. 
The contraction of the artery, and consequent reduction of the quantity and movement 
of the blood in the vascular plexus, was promoted by repeated applications of cold water 
(1 124); which in some instances stopped the motion of the blood altogether, by contract- 
ing the artery to so small a size that no blood-particles entered it. A solution of acetate 
of lead also produced this effect. 

The determination of blood thus excited produces an increased redness quite visible to 
the naked eye, but it is less intense and of lighter hue than the redness of inflammation 
or congestion. 



192 - . PROXIMATE ELEMENTS OF DISEASE. 

(in congestion), whicli seems contradictory ; but if the objector had duly 
considered my explanation, he would have found no contradiction in 
it. In determination, the vessels enlarged are the arteries, which, being 
near to the source of motion, and highly charged with its propulsive 
power give vent to the current as from a reservoir under high pressure ; 
whereas in atonic congestion the vessels enlarged are the veins and capil- 
laries, which are remote from the source of motion, and receive their 
impulse only through the arteries, which are not enlarged, or are even 
contracted (§ 294); and thus the accumulated blood becomes comparatively 
stagnant. There is nothing contradictory in this simple application of 
hydraulic principles ; and it is farther illustrated by the fact, that those 
parts are most liable to determination of blood which are nearest to the 
source of power ; thus the arteries of the head, face, and neck present 
this phenomenon much more frequently than those of the lower extre- 
mities. 

327. There appears, then, to be no difficulty in tracing local determi- 
nation of blood to the physical cause, enlargement of the arteries, lead- 
ing to the affected part ; and if it is not equally easy to give a physiolo- 
gical explanation of the cause of this enlargement, it is only because 
the laws of atonic contractility of arteries have not yet been sufficiently 
studied. The terms "active dilatation" (Hunter), and "vital turges- 
cence" (Kaltenbrunner), have been applied to the condition in question; 
but all that is known of animal physics is opposed to the possibility of 
there being a power of active dilatation in the arteries. 

The physiological cause seems to be a weakening or reduction of the 
tone (§ 123) of the artery ; so that it becomes passively distended by 
the vis a tergo of the heart and arteries. In some cases, it might be 
supposed that this weakness is the result of exhaustion from stimulation 
(§ 116); and it has been stated above that a momentary contraction of 
the artery precedes its dilatation. But the dilatation is out of all pro- 
portion to the previous contraction ; and, in some cases, as in blushing, 
in the operation of heat, and in the growth of parts, there is no sign of 
any previous contraction. 

328. Dr. Billing ingeniously conceives that, by stimulating the nerves, 
the nervous influence is drawn away from the vessels; and that their 
contractility, being derived from this influence, is thus impaired. But 
this view assumes that muscular irritability, even in its lowest form, 
tonicity, is a property derived from the nerves — an assumption unwar- 
ranted by the facts and opinions most generally received by physiolo- 
gists (§ 110). There can belittle doubt that the nerves — especially the 
sympathetic (§ 152) — are sometimes concerned in causing determination 
of blood; and it is not improbable that their influence is that of reduc- 
ing the contractility of particular arteries, just as strong moral emotions, 
acting through the nerves, paralyze the sphincters and muscles of vo- 
luntary motion (§§ 144, 154). So, too, we have found that heat, which 
in moderate degree increases the irritability of muscles, impairs their 
tonicity, and cold has the reverse effect (§ 120). But the laws of toni- 
city, and its relation to the nervous influence, require farther investiga- 
tion. 

329. We can readily understand tho final cause of determination of 



DETERMINATION OF BLOOD. 193 

blood. "Ubi stimulus, ibi fluxus." The flow is intended to support 
the well-being and function of the part. If any influence disturb its 
well-being, or excite its function, more blood is wanted; the arteries 
dilate to supply more, and in greater force, and thus the circulation 
through the part is augmented. The result is, in moderation, to in- 
crease the redness, warmth, sensibility, secretion, nutrition, and other 
functions of the part; in excess, to disorder and alter them. 

330. We have hitherto considered local determination of blood as re- 
sulting from causes which directly afi"ect that part of the vascular system 
in which the determination takes place. In not a few cases, however, 
the same result arises from opposite causes acting on other parts of the 
vascular system. Thus as we found external cold cause internal con- 
gestions by intropulsion (§ 292), so too it may occasion internal determi- 
nations of blood. By constricting the vessels of the surface and extre- 
mities, it directs the force as well as the quantity of the circulating fluid 
on internal parts, or those beyond its influence. Thus, in many persons, 
cold to the surface and extremities causes palpitation, dyspnoea, pain in 
the chest, throbbing, pain and heat in the head, gastralgia, colic, and 
fluxes of various kinds. It is obvious that, in such cases, the force of the 
heart is expended chiefly on the arteries of the internal organs, which 
thus become dilated, and the seat of determination of blood; whilst those 
of the surface and extremities are contracted and bloodless. The com- 
mencement of reaction from the cold stage of a fever is commonly 
marked by determination to the head and other parts near the centre of 
the circulation, which are thereby excited, and sufi"er more or less pain 
and disorder. 

The subjects in whom cold causes internal determinations of blood, 
are chiefly those endowed with much irritability of heart (§ 113), and 
with but little blood (§ 261). The same persons likewise are liable to 
a flush of blood to the face and head, with coldness of the feet, w^hen 
they go into a warm room. By cooling the head, the feet become warm ; 
or by warming the feet, the head cools. 

331. Attacks of local determination of blood, from other causes, are 
often accompanied by shivering fits, pallidity, coldness of the extremi- 
ties, and defective secretions, particularly in persons of weak circulation. 
When an unusual quantity and force of blood is determined to one part 
there must be less in other parts, which therefore suffer from the defi- 
cient supply. This furnishes an important therapeutic indication, to be 
noticed hereafter. 

332. As we find determination of blood to be chiefly produced by an 
enlargement of some arteries from a reduction of their tonicity (§ 326), 
so we may be led to expect that such enlargement may affect any part 
of the arterial system. We have chiefly considered it in relation to the 
distribution of blood to parts ; but it may also occur in the great arterial 
trunks. Inordinate pulsation of the aorta, especially in the abdomen 
at the cceliac axis, or at the bifurcation into the iliacs (corresponding 
with a little below the epigastrum and at the umbilicus), is a common 
symptom in nervous subjects. Epigastric pulsation, I have observed 
frequently before and after heematemesis. In several cases nephralgia, 

13 



194 PROXIMATE ELEMENTS OF, DISEASE. 

hsematuria, and lithic deposits in the urine occurred in patients affected 
with strong pulsation at the umbilicus. 



SYMPTOMS AND EFFECTS OF DETERMINATION OF BLOOD. 

333. Many of the symptoms of determination of blood may be learned 
from the preceding illustrations. It generally causes a flush of heat, 
and exalts contractility (§ 112), sensibility (§ 126), and other nervous 
properties (§ 149) of the part, exciting spasm, pain, irritation, and sym- 
pathetic disorder. In its moderate degrees, it increases the natural 
secretions of the part (§ 162), and thus becomes the cause of mucous, 
bilious, and urinary fluxes, &c. The nutritive function is a slow process, 
and only affected by determination of blood when constant or often re- 
peated ; then it is likewise increased, and more naturally than from con- 
gestion, the result being a more simple and general hypertrophy of the 
part. The process of absorption, although favored when the current 
is accelerated without distension, is often not equal to the effusion. 
Hence in sacs and cells determination of blood may cause dropsy. 

A few examples will suffice to illustrate the symptoms and effects of 
local determination of blood. 

334. The parts most subject to determination of blood are those 
nearest to the heart, and those most freely supplied with bloodvessels 
(§ 30), as the brain, the parenchyma of glands, mucous membranes, and 
the skin. 

335. Determination of blood to the head often takes place in some 
persons from mental excitement, violent exertion, stimulant drinks, or 
defective excretion. The symptoms vary considerably ; but increased 
beating of the carotid and temporal arteries, some flushing of the face 
and suffusion of the eyes, and an increase of the symptoms on stooping 
or lying with the head low, are commonly present in all cases. The 
other symptoms are sometimes those of simple excitement of the nerv- 
ous centres, painful throbbing in the head, excessive sensibility to light 
and sound, flashes in the eyes, noises in the ears, an excited state of the 
mind, rapid flow of ideas, sometimes bordering on delirium, wakefulness 
or dreamy sleep, restlessness and irritability of temper. Sometimes 
these symptoms are replaced by others indicating a temporary oppress- 
ion of nervous functions, such as giddiness, drowsiness, stupor, imperfect 
vision and hearing, with apparent specks or mist in the eyes, impaired 
articulation and power of locomotion, occasionally with various convul- 
sive affections, as in hysteria and epilepsy. 

336. It may seem difficult to explain how such opposite symptoms, 
those of excitement and those of oppression, are produced by the same 
cause — determination of blood. But the explanation is readily found 
on referring to the true nature of determination, and the different modes 
in which it affects the circulation within the head. Moderate excitement 
of the brain, as by bodily exercise, mental exertion, or certain beverages, 
such as tea or coffee, is accompanied by increased but equal flow of blood 
through the brain. But if these or other causes of excitement operate 
in excess, the arteries supplying the brain are still farther dilated, and 



DETERMINATION OF BLOOD. 195 

convey blood to it "with more force without an equal increase in the pas- 
sage of the blood through it ; and this for two reasons. 1. We have 
already found that a certain proportion in the size and elasticity of 
the vessels best qualifies them to transmit blood freely (§ 301) ; and that 
where this is wanting, increased force does not compensate for it, but 
often causes new disorder. Thus in violent palpitation of the heart, 
the aorta, carotid, and subclavian arteries are often dilated, and throb 
strongly ; but the weak pulse at the wrists shows that much force is ex- 
pended on the larger trunks, without reaching their distant branches. 
This too is one reason why, in determination of blood to the head, the 
force is sometimes more expended in the larger vessels at the base of 
the brain than transmitted throughout its substance. 2. Another rea- 
son for unequal or defective excitement from determination of blood to 
the head, is the unyielding nature of the skull, which permits no con- 
siderable enlargement of any of the vessels within it, without a corre- 
sponding diminution of other vessels, and a general compression of the 
cerebral substance. Hence distension of the arteries, beyond a certain 
degree, will compress and obstruct the small veins, and thus prevent 
that freedom of circulation on which functional activity depends. On 
these principles may be explained the production of symptoms of de- 
pressed as well as excited energy of the nervous centres, and often a 
mixture of both, from the same cause, determination of blood (§ 153). 

337. Determination of blood to the kidneys is caused by stimulating 
diuretic drinks, and, besides the increased flow of urine, may produce 
pain in the loins and throbbing in the abdominal aorta ; and the urine 
discharged may exhibit an increase not only of its water, but also of its 
acid matter, with more or less of the epithelial cells of the uriniferous 
tubes. Excitement of the circulation, by exercise or by nervous affec- 
tions, also reaches the kidneys ; exercise carries off much fluid by the 
skin ; but nervous excitement, where it fails to cause perspiration, de- 
termines more to the kidneys, and this seems to be the source of the 
abundant flow of limpid urine which follows convulsive and other nerv- 
ous affections. External cold operates in a similar manner, by constrict- 
ing the superficial and extreme vessels ; it directs the blood in unusual 
quantity and force on internal organs, especially the kidneys ; hence 
enuresis. 

338. Determination of blood to mucous memhranes is exemplified in 
certain forms of dyspepsia, in which sudden pain, or heat, or nausea, is 
felt in the stomach, accompanied by epigastric pulsation, and sometimes 
followed by eructation of sour or other liquid, and sometimes by hemate- 
mesis. These attacks are often induced by excitement, general or local, 
from irritant ingesta, and from external cold. In the intestines, a similar 
affection causes a diarrhoea ; in the air-tubes, bronchial flux ; the com- 
mon character of these affections being their sudden production under 
the influence of various exciting agents. 

339. Determination of blood to the skin is often produced, not only 
by direct irritation, but from the influence of internal causes ; as in case 
of blushing from mental emotion, flushing of the face from acid in the 
stomach, and the general redness of the surface in reaction after cold 
or at the commencement of fevers. In various chronic skin-diseases. 



196 PROXIMATE ELEMENTS OF DISEASE. 

the effect of determination is seen in a brightening of the color of the 
eruption, which may take place in a few minutes. 

340. Determinations of blood are commonly transient, coming on 
suddenly and soon subsiding. When they are more permanent, they 
commonly lead to other disorders. In their immediate seat, they cause 
either increased secretion, with the addition of more or less of the watery 
saline, and albuminous parts of the blood, or hemorrhage, or they may 
pass into inflammation. In other parts of the body, there is often, at 
first, coldness, and defective circulation and function (§ 330), but after- 
wards they may succeed a febrile reaction, with hot skin, accelerated 
pulse, scanty secretions, and other symptoms of inflammatory fever. 

341. The frequent recurrence of determination of blood, or its long 
continuance in a lower degree, affects the structure ; increased nutrition, 
hypertrophy, being the result. This may be a natural kind of hyper- 
trophy, as in the case of muscles, which augment in size in proportion 
to their exercise, which increases the circulation of blood through them. 
So the uniform hypertrophy of the substance of the heart, and of other 
organs, after long-continued excitement of that organ, may be referred 
to the increased determination of blood that has been kept up. In 
other cases parenchymata, as those of the kidneys and liver, exhibit 
alterations rather than mere growth ; and albuminous deposits and 
granular degeneration result. In these and other cases, the effect on 
the structure is commonly modified by the occasional presence of con- 
gestion^ inflammation, and the plastic condition of the blood itself (§ 2 11). 

It is unnecessary to dwell farther on the phenomena and results of 
determination of blood, as we shall have to advert to them in connection 
with its occasional results — flux and hemorrhage, and with inflammation, 
of which it is a component part. 

REMEDIES FOR DETERMINATION OF BLOOD. 

342. In the treatment of all cases of determination of blood, as of 
diseases in general, it is obviously proper, as much as possible, to re- 
move the exciting causes. Thus, in the numerous class of cases arising 
from the action of stimuli or irritants on the part which is the seat of 
the determination (§ 324), the removal of such irritants, or the diminu- 
tion of their action by soothing or diluent remedies, is a first indication. 

343. If we are correct in tracing local determinations of blood chiefly 
to an atonic distension of the arteries supplying the part (§ 326), we 
may expect measures which promote their contraction to be efficient 
remedies. This is the fact; for cold is one of the most effectual means 
which we possess for subduing determinations of blood; and this was 
mentioned as a chief remedy for the element, defective tone (§ 124). As- 
tringent agents are equally useful in some instances of local determina- 
tion; as in the application of solutions of acetate of lead, sulphates of 
zinc and copper, nitrate of silver, and other astringent lotions to ex- 
ternal surfaces (§ 326, note)', but these are chiefly effective where the 
determination is (piitc local and unconnected with generally increased 
circulation, otherwise they become irritants rather than astringents 
(317). But besides cold and other astringents to the part which is the 



DETERMINATION OF BLOOD — REMEDIES. 197 

seat of the determination, and to the arteries leading to it, derivants, or 
means which draw away blood by relaxing other parts of the vascular 
system, are especially indicated by many preceding observations (§§ 330, 
331, 340). Of these derivants, heat is the most effectual, especially 
when combined with moisture. 

344. Thus cold lotions or douche to the head, and the hot foot-bath, 
are among the best remedies for determination to the head. Taking 
copious draughts of cold water, or more sparingly of iced water, will 
often relieve epigastric pulsation and palpitation of the heart. The 
warm-bath, by deriving to the surface, will diminish the flow of blood 
to the kidneys. I have known severe nephralgia instantly relieved by 
cold affusion on the loins; but the practice is too hazardous to be recom- 
mended. 

345. Various evacuant remedies may also be employed to counteract 
determination of blood, by determining a flow in another direction; and 
thus purgatives, diuretics, and diaphoretics are often useful. Of these, 
purgatives are by far the most powerful and sure in their operation, and 
are of great efficacy in determinations to the head. Change of posture, 
by elevating the part which is the seat of determination, may sometimes 
be usefully practised. 

346. But the most powerful derivant is bloodletting, general or local. 
By the microscope, it may be seen how opening a bloodvessel changes 
the currents of blood; the currents of many vessels are reversed and 
drawn towards the bleeding point, whilst in others they are retarded 
where they were before running with great speed. But bloodletting is 
unnecessary and injurious in many cases of determination of blood, 
especially those attended with a deficiency of blood in the whole system, 
and, as we have seen, such cases are not rare (§ 330). Dry cupping is 
a good substitute in some instances; but even this measure is more 
weakening than it is generally supposed to be ; for much blood being 
extravasated into the skin and cellular texture, is really lost to the sys- 
tem as blood; its particles are changed, and their structure destroyed. 

The cases in which bloodletting should be used are those where deter- 
mination to an important organ is combined with some general plethora 
or local congestion, or has continued so long as to threaten a termina- 
tion in inflammation. A speedy blood-drawing, as by cupping or free 
venesection, will generally answer best. 

347. In the same class of cases, certain remedies are useful which 
seem to cause a general relaxation of the tonic fibres (§ 122) of the vas- 
cular system and an equalization of the force and blood which this sys- 
tem conveys (§ 331). Antimony is the chief of these; and it is most 
indicated where febrile reaction has begun. 

348. Another class of remedies suitable for determination of blood, 
attended with much excitement, are sedatives, or those w^hich reduce 
the heart's action (§ 115), such as digitalis, hydrocyanic acid, and nitre. 
These are chiefly useful where the determination occurs in connection 
with palpitation, as in the case of the various convulsive or other sud- 
den nervous attacks which I have proved to be so commonly excited by 
palpitation (§§ 322-3). I have entirely cured several cases of convul- 
sive hysteria, and much reduced the frequency of the fits in epilepsy, by 



198 PROXIMATE ELEMENTS OF DISEASE. 

these remedies, sometimes combined with cold affusion on the head in 
the morning, and the hot foot-bath at night (§ 331). Hydrocyanic acid 
probably operates chiefly on the organic excito-motory nerves, and by 
lowering their function prevents the undue excitement which they com- 
municate to the heart. In this respect it surpasses conium and hyoscy- 
amus, which are also sometimes useful in preventing determination of 
blood arising from nervous excitement. 

349. We have found (§ 330) that in many instances determination of 
blood to internal organs results from weakness of the circulation, and 
especially a want of tone in the whole vascular system (§ 123); so that 
under the operation of cold constricting the external vessels, or of irri- 
tations exciting internal organs, the latter monopolize most of the blood 
and force of the heart's action. In such cases, besides temporary means 
to equalize the circulation (heat to the extremities and surface, cold and 
astringents to internal organs, gentle exercise, friction, &c.), more per- 
manent remedies are to be sought in tonics, and various particulars in 
diet and regimen, which give strength to the contractile fibre (§ 124), 
and improve the quantity and quality of the blood (§ 271). 

Thus preparations of iron and bark are useful remedies in cases of the 
weaker kind ; mineral acids, iodide of potassium, mild bitters, and the 
slighter metallic tonics, nitrate of silver, sulphates of zinc and copper, 
are serviceable in others which will not bear the stronger tonics. In the 
use of any of these remedies, it is necessary to guard against their ex- 
citing effects on the parts which are the seats of determination, by pre- 
mising or conjoining the temporary remedies (§ 342, &c.) against that 
condition, and by keeping the secretions free and equally balanced. 

In all cases, country air, and exercise suited to the strength of the 
patient, and habits of posture opposed to the peculiar determination, 
will be found useful in removing and preventing this morbid affection. 



SECTION VI. 

RESULTS OF HYPEREMIA. 

350. Before we proceed to the third and more complex variety of local 
hyperremia, inflammation, we must notice some remarkable results to 
which the other varieties, when increased to a certain degree, tend, when 
yet short of the conditions necessary to constitute inflammation — I mean 
heynorrlcage, flux, and dropsy. These results have been already men- 
tioned as sometimes ensuing from plethora, congestion, and determination 
of blood ; and in describing hemorrhage, dropsy, and flux, it will be un- 

'ncccssary to do more than exemplify their occurrence in connection with 
these proximate elements, and to trace the farther peculiarities which 
distinguish each of these results. 

I. IIEMORRHAaE. 

351. When, in any form of hypergemia, the bloodvessels are distended 
to a great degree, they sometimes give way, and blood is effused. I 



EESULTS OF HYPEREMIA — HEMOERHAGE. 199 

shall give illustrations of the more common cases of hemorrhage pro- 
ceeding from the several kinds of hypersemia which have been already 
described. 

General plethora (§ 275) not unfrequently causes hemorrhage from the 
nose (epistaxis), from the stomach {Jidematemesis, vomiting of blood), from 
the rectum {haemorrJiois), and into or upon the brain {ajooplexy). The 
operation of each of these, except the last, is more commonly favorable 
than otherwise, in reducing the excessive fulness of the bloodvessels ; 
but they may be attended with unpleasant symptoms, and require con- 
trol. 

352. Congestion from venous obstruction (§ 289) produces hemorrhage 
in the cases oi j^ulmona^y apoplexy (hemorrhage into the parenchyma of 
the lungs), from obstructive disease of the left side of the heart; bron- 
chial hemorrhage and limmoptysis (spitting of blood) from tubercles in 
the lungs ; hsematemesis and bleeding piles from obstructions of the liver 
from disease or violent straining. 

353. Congestion from weakness of the vessels (§ 290) often causes 
hemorrhage in various dependent parts, in congestive fevers, and in 
various passive hemorrhages of weak subjects. A stooping posture has 
been known to cause cerebral hemorrhage (apoplexy). The erect pos- 
ture may bring on uterine hemorrhage (291). 

354. The congestion of the head from the intropulsive operation of 
cold (§ 292), sometimes leads to epistaxis and apoplexy ; that from pre- 
vious excitement of the stomach and kidneys in drunkards (§ 294), 
occasionally causes heematemesis and hmmaturia (bloody urine). The 
congestion of the kidneys in scarlatina, and in the cold stage of ague, 
is sometimes followed by hsematuria. 

355. Hemorrhage, from determination of blood (§ 322), is exemplified 
in cases of epistaxis and apoplexy, preceded by increased beating of 
the carotids, flushing of the face, &c. (§ 335); h^matemesis from various 
irritants in the stomach (§ 338) ; h8gmaturia from stimulant diuretics 
(§ 337); bloody dysentery from drastic purgatives, &c. (§ 324). So also 
we shall find hemorrhage to be a common concomitant or result of in- 
flammation. 

356. But all cases of general or local hypersemia now noticed, do not 
result in hemorrhage ; some additional element is wanting ; and this ad- 
ditional element may be either in the bloodvessels or in the blood. 

357. The bloodvessels are sometimes obviously in a diseased state. 
Inelastic and fragile from osseous or atheromatous deposit, or aneurismal 
dilatation, the arteries of the brain become ruptured under the influence 
of congestion or determination of blood. Softened and lacerable from in- 
flammation or mal-nutrition, bloodvessels give way in various structures ; 
and in this way, hemorrhage occurs from an inflamed stomach or colon, 
in tuberculated lungs, in a softened brain, and in a diseased uterus. 
Sometimes, actual ulceration or suppuration opens an artery or vein, 
and this is not a very uncommon cause of hemorrhage in chronic ulcera- 
tion, in suppuration of lymphatic glands or tonsils, and in malignant 
disease of the stomach, intestines, and uterus. Mechanical injury may 
rupture bloodvessels in the kidneys and nostrils ; hence the hsematuria 
and epistaxis which sometimes follow violent blows in the loins or on the 



200 PROXIMATE ELEMENTS OF DISEASE. 

nose. I have repeatedly known haematemesis to ensue from the act of 
lifting a heavy object from a height, which, with peculiar force, com- 
presses the liver. 

358. In other instances, the hemorrhagic disposition can be traced to 
a peculiar state of the blood, which is defective in fibrine (§ 196), but 
abounding in red particles (§ 184), as in petechial fevers, congestive 
apoplexy, hemorrhagic smallpox, and other exanthemata. But there are 
other cases, in which the disposition to hemorrhage prevails without any 
defect of jBbrine, or excess of red particles ; scurvy and purpura are ex- 
amples. In the former, there is found to be the very reverse of these 
changes (§§ 185, 196).^ It appears probable that an alteration in the 
quality of the red particles (§ 186) and fibrine (§ 203), is the real evil in 
these diseases. The readiness with which textures become stained with 
the coloring matter, the purple, brownish, or party-colored stains left by 
inflammation, and, in extreme cases, the altered appearance of the blood 
itself, seem to show the coloring matter to be diseased ; the failure of the 
healing process, and the remarkably loose and blood-stained appearance 
of fibrinous coagula, which form on the spongy gums or in wounds, seem 
to indicate a want of contractility and vital plasticity in the fibrine (§ 211). 
Farther microscopic observations are wanted on these subjects ; some 
have already been noticed (§§ 187, 203). 

359. Another question connected with hemorrhages relates to the 
mode in which the blood is effused. We have just seen that, in some 
cases, bloodvessels are distinctly ruptured (§ 357). But in other in- 
stances, blood has been poured out in considerable quantities from 
various mucous surfaces, and even from the skin, without any discerni- 
ble breach of vessels, or even of the surface. This statement has been 
made, particularly in regard to epistaxis, haematemesis, and some re- 
markable cases of hemorrhage from the skin, occurring successively at 
different parts of the body. Considering the size of the red particles of 
the blood, and the absence of any visible pores in the walls of the blood- 
vessels, even under the highest magnifying powers, it does not appear 
possible that the particles can escape from the vessels without rupture 
either of the particles or of the vessels. At the same time, it may be 
stated that in the frog, the red particles do pass through capillaries of 
caliber smaller than their short diameter; and in so passing, I have 
often seen them rolled up in the manner of an ice wafer. J. Hewson 
noticed the flexible and extensible property of the red corpuscles, and 
it has been confirmed by his commentator, Mr. Gulliver. The appear- 
ances of capillary apoplexy (cerebral hemorrhage), and hemorrhagic in- 
flammations of serous membranes, countenance the opinion that many 
minute vessels become ruptured at once, probably in connection with an 
altered condition of the blood; and such minute ruptures occurring in 
membranes, would not be discernible by common modes of examination. 
All cases of this description which have lately come under my notice, 
have included the element already noticed, an altered state of the blood 

1 In acute liomorrhafijic purpura, the fi])rinc is not deficient, for I have found the blood 
efFu.sod under the skin firmly coaguhited. I liavc before mentioned vn.y experience that 
purpura is generally connected with imperfect action of the liver (^ 171). 



RESULTS OF HYPERiEMIA — HEMORRHAGE. 201 

(§ 358), generally of the nature of uraemia (§§ 171, 249) or cholsemia 

(§ 250). 

VARIETIES OF HEMORRHAGE. 

360. Besides differences in seat, hemorrhages are distinguished into 
active or sthenic^ and passive or asthenic ; and the peculiarities of these 
varieties may be traced to the same elements as the corresponding 
varieties of general and local hypersemia (§ 279), excess and defect of 
the contractile power of the heart (§ 110), and of the tonicity of the 
arteries (§ 120). Thus hemorrhages, preceded or accompanied by the 
symptoms of sthenic plethora (§ 280), or with determination of blood 
(§ 322), are active or sthenic ; whilst those occurring in connection with 
asthenic plethora (§ 281), or with mere congestion (§ 287), are passive 
or asthenic. We may, therefore, refer to the symptoms described under 
these subjects for the precursory symptoms of each kind of hemorrhage. 

361. But when the hemorrhage begins, it may modify the previous 
symptoms in various ways, besides the new local signs which the dis- 
charge of blood produces. In active hemorrhage, the full, hard pulse 
of sthenic plethora becomes modified by a remarkable jerk or thrill, 
which is an important symptom where hemorrhage is only suspected. 
I have noticed this thrill in the pulse even when the loss of blood has 
been very trifling, and where no murmur accompanies the heart sounds; 
and I am therefore inclined to think that it depends on an unusual ab- 
ruptness of the heart's contraction (§ 113), combined with irregularities 
in the tonicity of arteries in different parts (§§ 326, 332) ; which cause 
these to react in successive jerks at each pulse, instead of simultane- 
ously. In fact, this same thrill sometimes is felt during a paroxysm of 
determination of blood to a part without any hemorrhage resulting. 

361. If the quantity of blood effused be large, and especially if its 
loss be rapid, syncope, or various degrees of faintness and weakness, 
may ensue. The pulse becomes small, weak, and often irregular, the 
surface and lips pale ; either consciousness, or the heart's action, may 
first fail, according to the posture of the patient (§ 70), and the condi- 
tion of angemia (§ 262) is induced. 

362. Even after this faint state has been induced, in- the course of a 
few hours the increased action (reaction) returns ; and it is under the 
influence of this that the pulse exhibits the greatest degree of the jar- 
ring or vibratory character ; so that it may feel like a loose wire twang- 
ing, or a rough file drawn under the finger. With this state of the pulse, 
palpitation, throbbing of the great arteries, and the various symptoms 
of partial nervous excitement described under the head of anaemia, some- 
times occur (§ 265). During this reaction, the hemorrhage may be re- 
newed. 

363. If the hemorrhage is inconsiderable, or if it be suddenly checked 
by styptics before the vascular fulness or determination has been re- 
duced, inflammation may ensue, with increasing strength and hardness 
of the pulse, heat of skin, and other symptoms of inflammatory fever. 
On the other hand, hemorrhage to a considerable extent may remove 
the hypersemia, and the various local and general symptoms of oppres- 



202 PROXIMATE ELEMENTS OF DISEASE. 

sion, fulness, tightness, pain, and functional derangement which it had 
produced. Thus we find headache and flushing often relieved bj epi- 
staxis ; pain and oppression in the chest by haemoptysis ; abdominal pain 
and pulsation by hsematemesis, mel^na, or hemorrhoidal flux. 

364. But the blood effused may produce various disturbances and 
symptoms in the parts into which it is effused. Within the head it 
presses on the brain ; and by interrupting the circulation through it, it 
may cause coma or paralysis (§ 273) ; or it may also break up the sub- 
stance of the brain, and cause death by syncope (§ 116) and asphyxia 
combined. In the lungs, the blood may at once suffocate by its quan- 
tity, or cause dyspnoea and cough until it is expectorated. Here, too, 
it sometimes breaks up the texture of the lungs, leading to serious dis- 
organization. In glands it forms swellings, or is mixed with and 
modifies their secretions, as in the case of hsematuria. In other com- 
plex textures, it produces swelling, often followed by local inflammation, 
as instanced in the cutaneous swellings of purpura hemorrhagica. 

365. Passive or asthenic hemorrhage may be preceded by symptoms 
of asthenic plethora (§ 281) or congestion ; may be accompanied by 
symptoms of exhaustion if the loss is profuse, of relief if it be moderate ; 
and anaemia may ensue from excessive loss ; or reaction, sthenic hemor- 
rhage, or inflammation, if the hemorrhage is too suddenly checked. The 
hemorrhage connected with an altered state of the blood, is generally of 
the passive kind, although excitement, or determination of blood (inoli- 
men hsemorrJiagicum), sometimes comes on here also. 



TREATMENT OF HEMORRHAaE. 

366. As hemorrhage is commonly a result of plethora, congestion, 
or determination of blood, the remedies for these morbid elements will 
be more or less needed in its treatment. But the necessity for using 
these remedies will much depend on the extent and seat of the hemor- 
rhage, and the mischief likely to result from its continuance. For ex- 
ample ; a moderate epistaxis or hemorrhoidal flux needs no treatment ; 
it is a natural cure for a previously existing hypersemia. But if these 
hemorrhages be profuse, whether of the sthenic or asthenic kind, they 
must be restrained ; if sthenic, by artificial bleeding, which is under con- 
trol, and by derivants to other parts, to reduce the fulness which causes 
the hemorrhage ; if asthenic, by stypics, combined with derivants, to 
save the blood, the loss of which is injuring the system. 

367. But in some cases, hemorrhage to any amount may be injurious, 
and should be opposed from the first, both by remedies for the hyperce- 
mia, which is the cause of the hemorrhage (§ 345, et seq.), and by styp- 
tics, which peculiarly counteract this result. Thus hemorrhage from 
the lungs, or into the ])rain or other organ, requires prompt interference. 
The same rule may be applied to cases of excessive hemorrhage of any 
kind in all cases, and of more moderate hemorrhage in very weak sub- 
jects ; in all of which the loss of blood is a pressing danger. 

368. In active hemorrhage, generally, bloodletting may be used until 
the hemorrhage is arrested or tlic pulse reduced; and this effect shcoild 



HEMORRHAGE — TREATMENT. 203 

be sustained by other evacuants, especially purgatives and diuretics. 
Remedies which diminish the power of the heart, such as digitalis, hy- 
drocyanic acid, and nitre, and those which also reduce the tonicity of 
the arteries, especially antimonial medicines, are likewise of great use 
in some active hemorrhages. Another powerful agent in hemorrhage, 
connected with increased action or determination of blood, is cold (§ 348). 
Thus ice, or a stream of cold water on the nose and forehead in case of 
epistaxis, ice, swallowed in hsematemesis, ice applied externally, or icy 
w^ater injected, for uterine hemorrhage is of considerable efficacy (§ 344). 
I do not approve of the practice recommended by some, of applying 
ice to the chest for haemoptysis ; I have seen pneumonia thus induced. 
Cold water is sometimes very effectual in arresting the flow of blood 
from a wound, and Dr. 0. Rees has suggested that, in addition to its 
constringent operation on the vessels, it may arrest the capillary circu- 
lation by causing the red particles to swell up by endosmosis. 

The treatment of passive or asthenic hemorrhage, besides styptics to 
prevent excessive loss of blood, will include remedies for general ple- 
thora (§ 286), or local congestion (§ 313, &c.), which may cause the 
hemorrhage. Hence, general or local depletion, derivants, accompanied 
or followed by tonics, may be useful. 

369. We have now to consider the means calculated to restrain all 
kinds of hemorrhage, and which are especially opposed to the causes 
which more immediately determine this result of disordered circulation 
(§ 356). If bloodvessels are softened, brittle, or actually ruptured or 
ulcerated (§ 357), a chief thing to be done is to diminish the quantity 
of blood sent to them ; and besides by bloodletting, this may be effect- 
ed by pressure, posture, cold and astringent applications, and means cal- 
culated to tranquillize the whole circulation. Thus epistaxis is sometimes 
arrested by pressure on the carotids ; uterine hemorrhage, by pressure 
on the abdominal aorta, or by elevating the pelvis ; haemoptysis, by 
keeping the chest high ; and in all cases of hemorrhage, perfect still- 
ness and a cool regimen should be observed. 

370. The other pathological condition which favors hemorrhage, the 
altered state of the blood (§ 358), is, perhaps, more directly influenced 
by the remedies called styptics. Most of these remedies are astringents 
causing contraction of the tonic fibres of vessels and other parts, but 
some of them also coagulate the blood, and in both these ways, they 
may tend to restrain hemorrhage. 

Of those which cause both contraction of the vessels and coagulation 
of the blood, the most powerful are acetate of lead, alum, sulphate of 
copper, chloride of zinc, nitric and sulphuric acids. Other styptics, as 
nitrate of silver, sulphate of zinc, sulphate of iron, and infusion of nut- 
galls, are certainly astringent, and are generally supposed to coagulate 
the blood ; but Mr. Blake's experiments show that they have not this 
latter effect, when injected into the veins of living animals (see note to 
§ 214). It is, however, possible that, in a concentrated form, as where 
applied topically, they may coagulate the blood in the bleeding vessels. 
This seems to be the effect of nitrate of silver when applied to leech- 
bites. The actual cautery operates in a similar way. 

In some cases of hemorrhage, the styptic remedies may be applied 



204 PROXIMATE ELEMENTS OF DISEASE. 

dkectly to the bleeding part, as in epistaxis, hsematemesis, hemorrhoids, 
and uterine hemorrhage. In epistaxis, solutions of alum, acetate of 
lead, and sulphate of zinc are sometimes injected into the nostrils, or 
applied by sponge or lint. In hsematemesis, sugar of lead, alum, gallic 
acid, oil of turpentine in small doses, and the mineral acids, given by 
the mouth, operate directly on the bleeding part. In excessive hemor- 
rhoidal flux, enemata, containing some of these remedies, are immediately 
beneficial. 

371. In many instances, the bleeding part is beyond the reach of the 
direct application of styptic remedies ; yet some of these, administered 
internally, show considerable power in restraining the hemorrhage. Thus 
hemoptysis is assuredly sometimes checked by frequently repeated doses 
of sugar of lead (which should be combined with a little opium or conium, 
to prevent its griping the bowels) ; and according to some practitioners, 
by ipecacuanha, gallic acid, alum, and other astringents. Hsematuria 
of the passive kind is diminished by small doses of oil of turpentine ; 
passive uterine hemorrhage, by gallic acid, ergot of rye, and tincture of 
the sesquichloride of iron. Opium given internally, has been found ef- 
fectual in some cases of uterine hemorrhage. It is difficult to explain 
how it operates ; but it is probably through that property by which it 
diminishes many secretions. 

872. In some kinds of hemorrhage, especially those of the intestinal 
canal, the most effectual remedies are those which increase the proper 
secretions of this canal, and of its allied glands ; such as mercurial and 
saline purgatives, in combination with others of a styptic kind, such as 
sulphuric and nitric acids, alum, and sulphate of zinc. This mode of 
treatment is often sufficient in slight hemorrhages, or dispositions to 
hemorrhage, from the lungs and uterus, and in purpura hemorrhagica ; 
and there can be little doubt that it operates on the condition of the 
blood, as well as by its evacuant and styptic effects. 



II. FLUX AND DROPSY. 

373. Another result of various kinds of hyper^emia, is an effusion of 
the watery part of the blood, with more or less animal and saline matter 
in solution. This result, occurring in secreting organs or open surfaces, 
constitutes fluxes ; in closed sacs or cellular texture, it constitutes drop- 
sies. There is so much that is in common in the pathology of fluxes 
and dropsies, that we shall avoid repetition by exemplifying them to- 
gether in the first place; and we can afterwards notice their distinguish- 
ing peculiarities. 

374. General plethora sometimes ends in flux or dropsy ; but such a 
result most commonly ensues where the bloodvessels are temporarily 
distended with an undue proportion of watery contents. Thus, if much 
water be slowly injected into the veins of an animal, the circulation and 
breathing become embarrassed; and after a time, dropsical effusions take 
place into the abdomen, the chest, and the cellular texture ; or a flux 
(excessive flow) takes place from the kidneys, intestines, or skin ; or all 
these results may occur ; and the bloodvessels are relieved of their dis- 



FLUX AND DROPSY. 205 

tension. The same events have sometimes arisen from excessive drink- 
ing of any liquid, but chiefly where the kidneys and the skin, the natu- 
ral emunctories for superfluous fluid in the body, have failed in their 
office. Thus drinking largely of a cold liquid when the body is perspir- 
ing and fatigued, weakens the heart's action, and checks the cutaneous 
and renal secretion ; the bloodvessels become filled to tension, and may 
relieve themselves in dropsical eff"usions or diarrhoea. External cold 
sometimes operates in a similar way ; it arrests perspiration, and causes 
internal congestions (§ 292) ; and if, from previous over-excitement or 
other defect, the kidneys are unequal to perform what the skin fails to 
do, general fulness is the result, which tends to issue in some dropsy or 
flux. The sudden suppression of a cutaneous eruption, or of the dis- 
charge from an old ulcer, has sometimes been followed by anasarca, 
diarrhoea, or bronchial flux (humid asthma). The colliquative sweats 
of advanced phthisis are of the nature of a flux, by which the bloodves- 
sels, in their obstructed and reduced state, relieve themselves of super- 
fluous liquid. These sweats may generally be stopped by a judicious 
restriction in liquid food. 

375. If we seek instances of local congestion terminating in flux and 
dropsical effusion, we easily find them in almost every variety of con- 
gestion that has been enumerated (§ 288, et seq.). In fact, these are 
the most common causes of partial dropsies. 

The adequacy of venous obstruction to produce dropsy, is well illus- 
trated by some experiments of Lower. He tied the jugular veins of a 
dog, expecting the animal to die of apoplexy ; instead of this result, the 
face and head of the animal became much swelled with oedema. He 
then tied the ascending cava ; ascites and anasarca of the lower extremi- 
ties were the results. Disease aff'ords numerous examples of dropsy 
arid flux from venous obstruction. Aneurisms of the arch of the aorta, 
or other tumors, by pressing on the venge innominatse, or descending 
cava, sometimes cause oedema of the face and upper extremities. In a 
case (under my care) of malignant tumor involving the roots of the 
lungs, there were hydrothorax, and flux into the bronchial tubes (bron- 
chorrhoea). In advanced pregnancy and ovarian dropsy, the legs swell 
from pressure of the tumor on the iliac veins. Many instances are re- 
corded in which occlusion of a large vein v/as followed by dropsy of the 
part from which the vein proceeded. The ascending cava has been 
found obliterated in persons who had long been aff"ected with ascites and 
anasarca of the lower extremities. In the University College collection, 
there is a drawing of such a case, in w^hich a supplementary circulation 
had been established by an enormous enlargement of the superficial 
veins of the abdomen. Dr. Watson relates an instance of the same 
kind.^ M. Tonnele has made some observations which favor the opin- 
ion, that chronic hydrocephalus is caused by a partial obliteration of 
the venous sinuses of the head (§ 267). 

But the most common causes of venous obstruction, are certain vis- 
ceral diseases, and these commonly produce either dropsy or flux. Thus 
the contractile disease of the liver, cirrhosis, is the most frequent cause 

' Library of Medicine, Art. "Dropsy," yoI. iii. 



206 PROXIMATE ELEMENTS OF DISEASE. 

of simple ascites ; and in connection with various functional and struc- 
tural diseases of the liver, diarrhoea and gastrorrhcea (watery eructations) 
are apt to occur. Structural disease of the heart, especially if seriously 
affecting the orifices or valves, commonly causes hydrothorax, bronchial 
flux (humid asthma), and sometimes general dropsy. Pulmonary con- 
gestion from causes impeding the respiration (§ 298), such as spasmodic 
asthma, emphysema, laryngitis, hanging, and coma, sometimes results 
in a bronchorrhoea or hydrothorax. In the experiments of Dr. J. Reid, 
a serous flux into the bronchial tubes ensued after the division of the 
par vagum, which, by impairing the respiratory action, induces pulmo- 
nary congestion.^ 

376. As we found congestion to arise from weakness of the circula- 
tion and atony of the vessels .(§ 290), so dropsical effusions and fluxes 
may proceed from the same causes. Thus oedema of the lower extre- 
mities is a common sign of extreme weakness ; as after severe illness, 
and towards the fatal termination of many chronic diseases. Colliqua- 
tive diarrhoea and perspiration (fluxes) sometimes occur under similar 
circumstances. The oedema and fluxes, which arise from weakness, will 
be more readily induced by postures which cause gravitative congestion. 
in the affected parts. Thus continued standing causes swelling of the 
legs, and leucorrhoea, in persons liable to these results of congestion. 

377. Fluxes and dropsical effusions sometimes occur after previous 
excessive excitement of the vessels of a part. Hence oedema after ery- 
sipelas, and the infiltration of serum in cavities and textures after exces- 
sive excitement of the vessels of these parts, even when no inflammation 
has been induced. The gleets or fluxes which follow inflammations of 
the urethra, bronchi, alimentary canal, and vagina, seem to be connected 
with the same condition of the vessels that sometimes causes congestion 
(§ 294). Persons who indulge in spirituous liquors often suffer in the 
morning from waterbrash, for which they find a glass of spirits the best 
remedy ; in this case, however, obstruction in the liver (§§ 56, 371) may 
also co-operate. 

378. Fluxes sometimes arise from the intropulsive operation of cold 
(§§ 77, 292); thus diarrhoea and catarrhal affections, too transient to be 
considered inflammatory, are frequently thus induced ; and diuresis (flux 
of urine) is a more healthy example of this effect of cold. It is doubtful 
whether this operation of cold will sufiice to cause dropsy ; but it may 
increase it where it existed previously. 

379. The other variety of local hypersemia, determination of blood 
(§ 321), may produce fluxes and dropsies. The influence of various stimu- 
lants on secreting organs and surfaces, illustrates the production of 
fluxes in this way (§ 324). Thus, snuff in the nose determines a flow of 
nasal mucus and of tears ; spices in the mouth provoke a discharge from 
the salivary glands ; irritating vapors inhaled cause a flux in the air- 
tubes ; purgative medicines induce a flux from the intestines, &c. In 
these cases, the irritation is short of inflammation, which, although at- 
tended with determination of blood and effusion, comprises farther effects. 
The fluid tlius secreted in these several cases of flux from determination 

' Edin. Med. and Surg. Journ. vols. xlix. li. 



FLUX AND DROPSY — PECULIAR CAUSES. 207 

of blood, differs from the products of inflammation ; it commonly consists 
of the natural secretion of the part, diluted with an unusual proportion 
of water and saline matter from the blood, and the excess of saline matter 
sometimes gives the secretion an irritating quality, as in the fluid of 
coryza, bronchorrhoea, and watery diarrhoea. 

Other examples of flux may be referred to determination of blood with- 
out special irritations ; as the leucorrhoea which precedes and follows 
the menstrual period, the bronchorrhoea or gastrorrhoea in some cases. 
excited by increased action of the heart, and the sweat succeeding to 
flushes of blood to the head or other parts. 

380. Dropsy is less frequently a result of simple determination of 
blood ; because, independently of inflammation, there are few causes for 
such determination to closed sacs. But probably the dropsy accompa- 
nying tubercles in the peritoneum and membranes of the brain, may in 
some degree be induced by the mechanical irritation of the tubercles 
causing a flow of blood to the membranes. The sudden mode of attack 
which tuberculous hydrocephalus sometimes exhibits, seems to counte- 
nance this opinion, being attended by the phenomena of determination 
of blood to the head, described before (§ 323), but here this proceeds to 
effusion of serum, with its more permanent symptoms. The kinds of 
dropsy called inflammatory may be included under this head ; but we 
shall shortly see that the determination of blood, or excitement of the 
circulation, present in such cases, is consequent on an altered condition 
of the blood itself. 

381. As flux and dropsy commonly arise from similar conditions of 
the vascular system, so they are sometimes found to succeed to one an- 
other. Thus Andral mentions a case in which hydrothorax was removed 
on the occurrence of a profuse flux from the air-passages. Examples 
are not uncommon of the subsidence of ascites on the occurrence of 
diarrhoea, or of the supervention of ascites, when a diarrhoea, of long 
duration, has b^een suddenly checked. Dr. Watson quotes, from Dr. 
Farre's lectures, an instance in which hydrocele was removed by violent 
purging. It is a more familiar fact that the occurrence of dropsy is at- 
tended by a marked diminution of the urinary secretion, and that a free 
flow of this often reduces the dropsy. On a knowledge of the preceding 
facts may be founded the most effectual treatment of dropsy. 

382. Enough has been said to show that flux and dropsy, as well as 
hemorrhage, are occasional results of hypereemiain its different varieties. 
But what are the circumstances which determine the occurrence and 
kind of these results? In the case of hemorrhage, we found the additional 
or determining cause to be in the vessels or in the blood (§ 350). So 
certain conditions of these favor the occurrence of flux and dropsy. An 
extreme amount of vascular distension will pretty certainly result either 
in rupture and hemorrhage, or in the exudation of the watery parts of 
the blood (§§ 305, 340), and the long continuance of congestion or ple- 
thora, by making the exhalation predominate over absorption, rarely fails 
to lead to similar consequences. But in some cases, both dropsical effu- 
sions and fluxes take place with a facility disproportioned to the amount 
of hypersemia or to its duration ; and in these cases the cause may be 
traced to a generally lax, flabby state of the tonic and contractile fibre 



208 PROXIMATE ELEMENTS OE DISEASE. 

(§ 123), or to a poor watery state of the blood (§ 222), or to both these 
conditions together. Persons liable to these affections are usually of 
pale complexion and phlegmatic temperament (§ 40). ♦ 

The influence which relaxation of the solids has in producing proflu- 
vial and hydropic affections, is exhibited in the occurrence of these results 
in parts after over-excitement (§ 294), where there is no indication of 
general disease of the blood. But in cases also in which the blood is 

o 

diseased, there is usually a relaxed state of the vascular fibre ; and it is 
not easy to distinguish the separate influence of these causes. Thus the 
liability to dropsy and fluxes, after long fevers, defective nourishment 
(§§ 63, 196), or confinement in impure air, must be attributed to the 
joint operation of both classes of causes. 

383. The conditions of the blood tending to watery effusions, require 
farther consideration. A poor or watery state of the blood, above 
noticed, is the most obvious of these ; and that this alone is sufficient is 
plain, from the fact that injecting water in quantities into the veins of 
an animal, will cause watery effusions or discharges, whilst the injection 
of blood or serum does not produce this effect. Persons who have lost 
much blood are liable to become dropsical from the same cause ; the 
bulk of the lost blood is replaced by watery serum absorbed from various 
sources ;: and thus the blood is in a diluted state (§ 264). The mode in 
which a watery blood tends to produce dropsy and flux, is not merely by 
the greater proneness of thin fluids to transude through the walls of the 
vessels, but also by the failure and irregular distribution of the force of 
the circulation. It has been already explained, under the head of anaemia 
(§ 262), that a scantiness of blood embarrasses the circulation. The 
structure of the heart, its valves and vessels, is adapted to certain de- 
grees of spissitude and quantity of the blood ; and when these vary much 
from the natural standard, when the blood, instead of being of an unctu- 
ous fluidity, is watery and squashy^ the hydraulic and moving apparatus 
of the heart and vessels is less capable of effecting its propulsion ; and 
this condition of the blood may thus not only facilitate watery effusions, 
but promote the congestions and other imperfections in the circulation 
with which flux and dropsy are commonly connected. 

384. Several of the circumstances which induce the thin state of the 
blood, have been already stated (§§ 222, 249, 382), and in its relations 
to dropsy, we would more particularly advert to imperfect excretion by 
the kidneys, liver, and skin, as the most common cause. In various 
forms of hypersemia, which lead to dropsy and flux (plethora, conges- 
tion, and determination of blood), it will be generally observed that 
these results ensue in proportion as the excreting organs fail, and that 
the removal of these results is to be effected chiefly by means which re- 
store or compensate the defective excretion. In many instances, ex- 
posure to cold has been followed by dropsy; and at first sight, this 
might seem to operate merely by checking perspiration, and thus retain- 
ing in the vessels water that should be eliminated, and which is then 
effused within the body. But checked perspiration alone will not cause 
dropsy ; tlierc must be a failure also in the action of the kidneys before 
this result will ensue. If these act properly, checked perspiration may 
disorder the circulation, and cause congestions, inflammations, and even 



FLUX AND DROPSY — CAUSES. 209 

fluxes; but I have never met with a case of dropsy arising from exposure 
to cold, in which the urine was not diseased, and, in the great majority 
of instances, albuminous. 

The circumstances under which exposure to cold induces dropsy, are 
such as also impair the action of the kidneys. A man in a fit of intoxi- 
cation lies for several hours of the night on the cold damp grass; he 
arises much chilled, has shivering succeeded by fever, and general dropsy 
ensues; the urine is very scanty, and, on examination, is found to be 
highly albuminous. The vital properties of the kidneys had been ex- 
hausted by the excitement of the stimulant beverage, so that when cold 
checks the perspiration, and throws the blood on internal organs, the 
kidneys cannot perform their vicarious action ; their vessels become dis- 
tended with blood, and mechanically exude serum, instead of separating 
the proper constituents of urine (§ 309) ; these and the superfluous water 
accumulate in the blood, and by their quantity and irritating qupJity 
cause efi"usions of serum containing urea in different parts of the body 
as well as various other functional disorders before noticed (§ 170). 

Another instance of a similar kind of general dropsy is that super- 
vening after scarlatina. This has been ascribed by some to a subin- 
flammation of the cellular texture, originating in the eruption; by others 
to the diseased state of the skin, left by the eruption, suppressing the 
perspiration. But if either of these were the true cause, the dropsy 
ought to occur most in the cases in which the eruption is most abundant, 
which is by no means the fact ; nay, I have treated seYeral patients in 
whom anasarca followed a scarlatina fever, with sore throat, w^ithout 
any rash at all. But in all these cases the urine has been albuminous, 
which again shows that the diseased action of the kidney is the most 
essential lesion connected with general dropsy. How scarlatina impairs 
the function of the kidney is a question too extensive to be discussed 
here ; but I will simply state my belief that it does so by causing in 
these glands a highly congested state, w4iich injures their secreting 
power (§ 304), as a parallel effect is observed with regard to the liver in 
bilious and intermittent fevers. A female under my care with albumi- 
nuria, which was almost cured, was attacked with mild scarlet fever ; the 
urine which had been merely hazy by heat and nitric acid, now became 
highly coagulable, and continued so until the fever declined, when the 
albumen again gradually decreased. 

The general dropsical state occurring towards the fatal termination of 
structural disease of the heart, I have in several cases found to be con- 
nected with albuminuria and slight jaundice, and I have been long in 
the habit of pointing out these as the most surely fatal complications to 
which heart diseases naturally tend ; their connection has been before 
noticed (§§ 305, 309). 

885. The pathological effects of secretion of serous and scanty urine 
(oliguria) have been already described (§§ 170, 249), but we must advert 
to the mode in which it induces dropsy and flux. Where resulting from 
a suddenly operating cause, such as exposure to cold, or scarlatina, a 
febrile state is generally present, with a frequent and hard or sharp 
pulse, heat of skin, thirst, &c. These symptoms occurring in connection 
wdth anasarca, have led to the use of the terms inflammatory, febrile, 
14 



210 PROXIMATE ELEMENTS OF DISEASE. 

acute, or active dropsy ; and so far as these terms only imply an excited 
state of the vascular system, they cannot be objected to. But some 
have employed them to explain the cause of the dropsy, as if this proceeded 
merely from the excitement or inflammatory condition. That such a 
condition is present, is obvious not only from the febrile symptoms just 
mentioned, but also from the buffy state of the blood drawn, and from 
the dropsical effusions and fluxes being in many cases combined with 
the symptoms and products of inflammation. Thus the anasarca is 
often attended with great tenderness, and sometimes with an erysipelat- 
ous redness; swellings of the joints frequently have the character of 
rheumatic inflammation ; effusion in the abdomen and pleura is often 
accompanied by pain or tenderness, and after death, slight deposits of 
lymph are found in addition to the serum ; catarrhal flux from the bron- 
chi, and diarrhoea, are associated with symptoms of more irritation 
(spasm, constriction, cough, vomiting, pain, and soreness) than occur 
with simple fluxes. 

Now, this inflammatory character may be readily explained, by refer- 
ring it to the irritating quality of the excrementitious matter which the 
failing function of the kidneys leaves in the blood. Under such circum- 
stances, urea has been found in the blood, and in various effusions 
(§ 170), and may be fairly regarded as the materies morhi which irri- 
tates various parts, and from which, whilst the system seeks to relieve 
itself (§ 17), excitement and sundry effusions or discharges ensue. In 
two points, this 'condition resembles acute rheumatism (§ 351): 1. In 
the number of parts which may be simultaneously or successively affect- 
ed. 2. In the w\^nt of any constancy in the seat of the affections. Both 
these points indicate that the cause is not essentially in any part, but 
in the blood. Another circumstance which approximates these affections 
to gout and rheumatism, is the nature of the excrementitious matter 
•which accumulates in the blood. In the latter affections, there is good 
evidence that lithic and lactic acids are the chief ingredients of this 
matter (§ 256); but I have so commonly found an exces's of urea in the 
urine of patients recovering from rheumatism, and the chief remedies 
for gout and rheumatism so distinctly increase the elimination of this 
principle (§ 257), that we can scarcely doubt that, in these affections, 
urea also is either produced in excess, or insufficiently excreted. The 
proximity in composition betw^een lithic acid and urea, and the proba- 
ble conversion of the former into the latter {Liehig), should not be for- 
gotten. Both gout and rheumatism, like oliguria, sometimes produce 
fluxes or catarrhal affections. Lastly, the connection between these 
affections is apparent from the fact, that rheumatism is frequently com- 
plicated with albuminuria (as after scarlatina) ; and granular degenera- 
tion of the kidneys (Bright's disease) is apt to supervene in the most 
aggravated forms of rheumatism. 

386. But, besides the retention of excrementitious matter in the blood, 
there is a loss of albumen from this fluid. That this loss, by thinning 
the blood, facilitates dropsical and profluvial effusions, is most probable 
in all instances; but this seems to be the especial cause of these results 
in the more chronic cases, and in the most anaemic subjects; for in these, 
as it has l)een already stated (§ 264), the blood is thinner and more 



FLUX AND DROPSY — CAUSES. 211 

watery than in any other disease. Thus in advanced stages of granu- 
lar degeneration of the kidneys, and sooner in anaemic subjects, almost 
every congestion, or determination of blood, ends in watery effusion. 
As the powers of the circulation fail, the effusion is connected chiefly 
with gravitative congestion (§ 291), and occurs most in the lower extre- 
mities ; in this respect differing from the dropsy of acute albuminu- 
ria, in which the swelling also affects the face, trunk, and upper ex- 
tremities. This form of dropsy is well entitled to the appellation 
asthenic, or passive, both from being connected with congestion and 
weakness of the circulation, and from the poor condition of the blood, 
and depressed or cachectic state of the functions dependent upon it (§§ 
185, 262). 

387. From the preceding statements, it may be inferred that acute 
dropsy arises chiefly from the retention in the blood of excrementitious 
matter and water which the kidneys fail to eliminate ; and that the more 
chronic or asthenic kinds, although often originating in the same way, 
are rather dependent on a poor or watery state of the blood, especially 
deficient in albumen (§ 222). This deficiency in many cases arises 
both from the continued drain by the loss of serum in the urine, and 
from the imperfect assimilation and nutrition connected with this state. 
But we have good evidence that the more chronic and asthenic forms of 
dropsy may arise from the same state of the blood, independently of 
disease' of the kidneys. Thus Andral and Delafond found dropsy in 
anaemic sheep in connection with clistomata in the liver, only in those 
cases in which the albumen of the blood was below the natural standard. 
So, too, in the human subject; the dropsy induced by very scanty or poor 
food, or close confinement in unhealthy places or malarious districts, and 
that supervening in extreme states of debility or cachexia, are probably 
dependent, not merely on weak or obstructed circulation, but also on an 
imppverished condition of the blood itself. For the same reason, the 
various structural diseases which cause congestions, especially those of 
the heart and liver often do not induce dropsy until the quality of the 
blood is impaired, either by imperfect excretion or by inadequate nutri- 
tion. 

388. We have thus traced flux and dropsy, in common, to elements 
previously considered ; hypersemia, in some of its forms, together with a 
diseased condition of the blood itself (§ 222), dependent on defective 
excretion (§§ 249, 250), or defective nutrition or assimilation (§ 268). 
The latter element, although not essential to the production of fluxes 
or local dropsies, is the chief cause of general dropsy, and constitutes 
the dropsical diathesis. If we endeavor farther to distinguish between 
the pathological causes of flux and dropsy, we find from observation 
that flux more commonly results from determination of blood or con- 
gestion, with a lax state of the solids (§§ 123, 382); whilst dropsy is 
rather associated with the altered condition of the blood just noticed. 

389. The distinction just made between the causes of flux and dropsy, 
implies that flux is generally a more partial, disease than dropsy, many 
circumstances relaxing the vessels of a part, without affecting the con- 
dition of the blood in the whole system. This is especially apt to occur 
m secreting organs and surfaces, which are, in fact, the common seat 



212 PROXIMATE ELEMENTS OF DISEASE. 

of fluxes. We have before noticed excessive secretion as a primary 
element of disease (§ 162), but the fluxes which we are now considering 
consist less in excess of the natural secretion (although this often occurs 
also), than in the addition of a (watery, saline, and sometimes albuminous 
fluid derived from the blood, a serosity in fact (§§ 305, 376). The fluids 
discharged in chronic coryza, bronchorrhoea, gastrorrhoea, and watery 
diarrhoea are the natural mucus of the respective surfaces, much diluted 
with a thin serum, the saline matter of which often gives the secretion 
an irritating property. Sometimes this serous fluid is substituted for 
the proper secretion, as in the coagulable urine of the more advanced 
stages of Bright's disease. 

The circumstances which commonly induce flux in secreting surfaces, 
have been already noticed (§ 376, et seq.), but after a flux has continued 
for some time, it is apt to become habitual, apparently through perma- 
nent relaxation of these affected vessels. These become so weak that 
any circumstances disordering the circulation may bring on an attack 
of the flux. In fact, the flux becomes an outlet for superfluous fluid in 
the bloodvessels, and for discharges which ought to be evacuated through 
the kidneys, skin, or bowels. 



GENERAL TREATMENT OF FLUX AND DROPSY. 

390. As there is much that is common to fluxes and dropsies, we may 
abridge our notice of the remedial measures to be opposed to them, by 
first giving the treatment applicable to both, and afterwards specifying 
that indicated for each class of results. 

In so far as fluxes and dropsies depend on plethora, sthenic or asthe- 
nic, congestion, in all its varieties, or determination of blood, the reme- 
dies for these several morbid elements (§§ 283, et seq., 313, et seq., J42, 
et seq.) must form part of the treatment. So, also, according to the 
prevalence of these constituent conditions, fluxes or dropsies may be 
more or less sthenic or active, or asthenic or passive, and more or less 
constitutional or local ; and the treatment must be varied correspond- 
ingly. And according to whether these conditions are tractable or not, 
fluxes, and dropsies resulting from them, may be more or less difiicult 
to remove, and exhibit many varieties as to duration and disposition to 
return. Thus fluxes and dropsies which arise from congestions 'caused 
by structural disease of the heart or liver, or by tumors compressing 
veins (§ 375), although often removed for a time, are likely to return ; 
but those arising from cold (§ 378), weakness (§ 376), previous excite- 
ment (§ 377), or functional disorder, may, in many cases, be cured per- 
manently. 

391. We have repeatedly stated the circumstances under which vas- 
cular congestion or fulness in itself suffices to induce dropsy and flux 
(§§ 306, 383) ; and under these circumstances, the remedies for conges- 
tion and plethora are the first and most important to be used. Thus 
in dropsy or fluxes suddenly induced by structural disease of the heart 
and liver, often brought on by cold, over-exertion, or excitement, whilst 
the condition of the blood has not materially suffered, depletion, general 



FLUX AND DROPSY — TREATMENT. 213 

or local, is advantageously premised before the use of other measures. 
Then follow remedies which, by increasing the secretions, reduce the 
remaining congestion and the effusions resulting from them ; combina- 
tions of mercury or antimony with squill and digitalis are peculiarly 
serviceable in accomplishing this object. Various other means contri- 
bute to the same end, chiefly those which act as evacuants and deriva- 
tives. This treatment approaches to the antiphlogistic, as we have 
already found the nature and products of congestion of high tension, 
and of sthenic plethora, approximate those of inflammation (§ 307). But 
in the more peculiar causes of flux and dropsy — those that induce these 
results with slighter amounts of congestion or disordered circulation 
(§ 382) — those which constitute the dropsical and profluvial diathesis 
(§ 388) — we find conditions generally betokening weakness, and requir- 
ing a tonic or more supporting plan of treatment ; a relaxed state of 
the solids, and a watery condition of the blood. But even in the treat- 
ment of these cases, to derive from the weak or congested parts, and 
to increase defective excretions, are objects generally to be attempted. 
Farther details will be better described under separate heads of flux and 
dropsy. 



TREATMENT OF FLUXES. 

392. In all cases of flux, it is proper to derive from the aifected part, 
and to promote the natural excretions in other directions, by some or 
other of the following means : warm bathing, warm clothing, exercise, 
friction, and stimulant applications to the surface, diaphoretic, diuretic, 
and aperient medicines. It is also necessary to avoid circumstances 
which promote congestion or determination of blood in the afl'ected part; 
such as dependent position, exposure to heat, cold to other parts, too 
fluid a diet, &c. In addition to these measures, it may be requisite to 
use others to counteract or remove the irritations or obstructions which 
the flux causes in the part which it afi'ects. Thus demulcent and narco- 
tic remedies are sometimes useful in catarrh and diarrhoea, to soothe 
irritation caused by the secreted fluid ; at other times, expectorants and 
purgatives, to promote its expulsion. 

393. The farther treatment of fluxes will be guided by the state of 
the vascular function, whether sthenic or asthenic. As in cases of 
hemorrhage, so with flux, it is sometimes attended by a hard, frequent 
pulse, heat of skin, and other signs of fever or of sthenic plethora ; here 
evacuants, antimonials, sedatives, and even bloodletting may be required. 
In fact, the disease borders on inflammation, and needs a similar treat- 
ment. Some cases of flux, of a sthenic character, arise from gouty or 
rheumatic matter in the blood ; here colchicum and alkalies are the pro- 
per remedies, as they promote the removal of this matter by the kidneys. 
Others we have found to be connected with albuminuria (§ 380), and 
are to be treated as dropsy from that cause. In all these examples of 
sthenic or active flux, it is neither useful nor safe to attempt hastily to 
check the discharge by astringent remedies, lest the determination of 
blood attending it end in a worse result, hemorrhage or inflammation. 



214 PROXIMATE ELEMENTS OF DISEASE. 

394. The majority of fluxes are, however, asthenic, connected with a 
weak state of the vessels, local or general ; and here other remedies are 
needful. Together with more or less of the general measures above de- 
scribed (§ 392), it is here safe and proper to endeavor to check the pro- 
fuse exhalation, by astringents, stimulants, and general tonics. Astrin- 
gent remedies are most effectual bj direct application ; and their mode 
of action, by constricting the relaxed vessels (§ 388), is obvious. Thus 
acetate of lead, sulphate and acetate of zinc, sulphate of copper, nitrate 
of silver, alum, and some vegetable astringents, are effectual in leucor- 
rhoea and diarrhoea. Some of these remedies seem also to act through 
the medium of the circulation. Thus sugar of lead, sulphate of zinc, 
sulphate of copper, and mineral acids, given internally, sometimes dis- 
tinctly diminish bronchial flux and profuse perspiration, as we have al- 
ready found they sometimes arrest hemorrhage (§ 367). Some fluxes 
are remarkably checked by remedies whose operation seems to be rather 
stimulant than astringent. Thus spices, essential oils, and brandy, 
sometimes cure pyrosis and diarrhoea ; cantharides diminish leucorrhoea; 
cubebs and copaiba, gonorrhoea ; balsams of copaiba and Peru occasion- 
ally check bronchorrhoea. It is uncertain how these remedies operate ; 
but it is probably in removing congestions by causing determination of 
blood, which excites contraction, and improved tone of the capillaries of 
the part (§ 317). They are most successful in asthenic cases originat- 
ing from inflammation. Another remedy occasionally useful in control- 
ling fluxes, is opium ; its mode of operation is equally uncertain ; but it 
is probably connected with its power to diminish natural secretions 
(§ 166). Its efiicacy is most obvious in diarrhoea and diuresis ; and it 
is sometimes beneficially combined with metallic astringents in bronchial 
and gastric flux. 

The state of the system in persons subject to fluxes is generally one 
of relaxation, and is therefore benefited by tonic medicines. Some of 
these have also an astringent property, which peculiarly adapts them for 
the treatment of asthenic fluxes. Thus the tincture of the sesquichloride 
of iron is useful in the treatment of leucorrhoea and humoral asthma, 
attended with much debility; infusion of cusparia in diarrhoea; and bark 
or quinia with mineral acids, gallic acid and tannin, in various fluxes 
in very relaxed habits. 

For similar reasons, the diet should be as generous as the digestive 
organs will bear ; sometimes including animal food twice a day, and a 
moderate allowance of some sound fermented liquor. Excess in liquid 
food should be particularly avoided, especially tea, and warm slops 
generally. Catarrhal colds, which are acute fluxes, I am in the constant 
habit of curing simply by total abstinence from liquids during two or 
three days; and although this extent of dry regimen is obviously inappli- 
cable to chronic cases, yet moderation in the use of liquids, especially 
before or during exposure to cold, is an important part of the treatment 
in all cases. I have known several instances of chronic coryza, bron- 
chorrhoea and diarrhoea kept up, if not brought on, by immoderate indulg- 
ence in tea and sucli liquids. These fluids cause a temporary plethora, 
which immediately finds vent through the lax vessels of the weak part 
(§ 389). The propriety of warm clothing, regular exercise, and a brae- 



DROPSY — TREATMENT. 215 

ing, but not too cold an atmosphere, is obvious from the previous con- 
siderations. 

TREATMENT OF DROPSY. 

395. In addition to the means requisite to remove the variety of hy- . 
persemia inducing the dropsy (391), we have to remedy, as far as we 
can, those conditions of the blood which we have found (§ 384) specially 
to favor the occurrence of dropsy. Of the causes of these, a failure in 
the secreting power of the kidneys is the chief; its sign being a scanti- 
ness of the urine, a deficiency of the natural constituents of this excre- 
tion, sometimes with an accession of albumen. The treatment must, 
therefore, have regard to the condition of the kidneys, which is the chief 
cause of this failure in their action, and to the state of the blood and 
other parts, which is the result of that failure. 

We have several times pointed out (§ 309) reasons for supposing a 
highly congested state of the kidneys to be the first cause of that failure 
in their function which induces albuminuria and its consequences. The 
means found most successful in removing dropsy arising from renal dis- 
ease, correspond well with this view. Thus in acute or inflammatory 
dropsy, occurring after scarlatina, or exposure to cold (§ 384), blood- 
letting, especially by cupping to the loins, hydragogue purgatives, and 
diaphoretics are advantageously used at first ; and subsequently some 
kinds of diuretic medicines, particularly tincture of cantharides, digitalis, 
and colchicum sometimes restore the natural action of the kidneys. 
Such measures, if employed at an early period, before the disease in the 
kidneys has affected the structure, are often completely successful. They 
fulfil, not only the indication of diminishing the renal congestion, but 
that also of purifying the blood from excrementitious matter, and in re- 
ducing the sundry effusions, local irritations, and disturbance which 
this matter excites in various parts (§ 385). They cure the dropsy by 
exciting artificial fluxes (§ 381). 

Of the hydragogue purgatives used in the treatment of acute dropsy, 
I have found cream of tartar in large doses (5iv. to 5x, every morning 
or every, alternate morning), and extract of elaterium (J gr.), the most 
effectual. Tartarized antimony, alone, or combined with opium, is the 
best diaphoretic, and it often relieves the catarrhal symptoms commonly 
present. Care must be taken not to cause vomiting, to which there is 
often a natural tendency. Dr. Osborne recommends the vapor-bath, 
and Dr. Watson the hot-air bath, as means of deriving to the surface, 
and causing perspiration. After cupping to the loins has been repeated 
as often as the strength of the patient may indicate, in obstinate cases 
I have seen much benefit from blisters or other counter-irritants to the 
loins ; and in asthenic cases, which do not bear the loss of blood, large 
blisters may be used at first with great advantage. 

The dropsical effusions are often soon dispersed by the preceding 
measures ; but the proof of the permanent benefit of the treatment is to 
be looked for in the progressive decrease of albumen, and the increase 
of urea and lithic acid in the urine. It often happens that, after the full 
use of depletion, cathartics, and diaphoretics, the condition of the urine 



216 PROXIMATE ELEMENTS OF DISEASE. 

becomes stationary, and does not advance towards a healthy standard. 
Then the diuretics before named are sometimes very effectual in aug- 
menting the quantity of urine, without increasing the albumen in it ; 
and where this is their first effect, their continuance will often produce 
a gradual diminution of the albumen. The tincture of cantharides is 
more powerful than the others in exciting the action of the kidneys ; and 
where it increases the urine, the dose may be augmented from ^x to 
i^xx or 5ss thrice a day ; but if the smaller dose do not act as a diuretic, 
it is not safe to proceed to the larger, nor, in fact, to persist with the me- 
dicine ; for if it irritates the kidneys without increasing their secretion, 
it is sure to do harm. We have noticed the same circumstance in the 
treatment of congestion by stimulants (§ 317); if they fail to remove 
the congestion, they aggravate the mischief. Digitalis and colchicum 
are safer diuretics, inasmuch as they are less irritating to the kidneys ; 
but they are also less powerful. 

Mercury might be expected to be useful in removing congestion or 
low inflammation in the kidney, and in restoring its secretion ; but it so 
speedily and severely salivates in such cases, without any equivalent 
benefit, that it is not generally eligible. The promptitude with which 
the gums are affected with mercury may be ascribed partly to the faci- 
lity with which inflammations may be excited in any part (§ 385) ; and, 
in some measure, to the failing action of the emunctories of the system 
permitting the mercury to accumulate more speedily than usual (§ 260). 
But mercury is peculiarly efficacious in dropsy connected with diseased 
liver ; and, in combination with squill, digitalis, and henbane, or conium, 
forms the most useful diuretic in all recent cases of dropsy dependent on 
congestion without disease of the kidneys. 

396. We have found (§§ 386, 387) that the asthenic forms of dropsy, 
and those of the most chronic character, are commonly connected with a 
watery, non-albuminous state of the blood, and general weakness of the 
system. To obviate this condition so far as possible by nourishing diet, 
tonics, and means to increase the strength, becomes here a leading indi- 
cation. In cases depending on malnutrition or mere debility (§ 387), this 
tonic-supporting treatment may be sufficient to effect a cure. In the 
commoner examples of dropsy, rendered asthenic by the long continuance 
of structural disease of the kidneys, liver, or other organs, the same 
strengthening and invigorating measures must be more or less combined 
with means to excite the failing excernent organs, or to produce some 
compensating discharge. Thus in dropsy from chronic albuminuria, or 
advanced degrees of granular degeneration of the kidney, the occasional 
exhibition of hydragogue purgatives and diaphoretics, and of the diuretics 
before mentioned, is useful, at the same time that bitters with iodide of 
potassium, or mineral acids, are given to keep up the general strength 
and powers of nutrition. In the more anaemic cases, iron is often of ad- 
vantage; but it sometimes proves injurious by impairing the little secret- 
ing power remaining in the kidneys, and by rendering the urine more 
albuminous. Where it has this effect, its use must be abandoned. The 
preparations of iron that I have found most serviceable in these cases, 
are the ammonio-citrute in combination with iodide of potassium and 
the muriated tincture. 



DROPSY — TREATMENT. 217 

Asthenic dropsy arising from diseased liver is sometimes signally re- 
lieved by mercurial and diuretic medicines, followed by or even conjoined 
with columba, bark, and other vegetable tonics. In several cases under 
my care, ascites, of great extent and long duration, connected with gran- 
ular degeneration (cirrhosis) of the liver, has been removed, and the 
patients have been for a time restored to apparent health, by a course of 
hydragogue doses of cream of tartar every morning, or every other morn- 
ing, with bark and nourishing diet in the day. Hydragogue purgatives 
are more directly useful in removing ascites connected with diseased 
liver, inasmuch as they excite a discharge from the congested vessels 
themselves, and substitute abdominal flux for abdominal dropsy (§ 381). 
But they often fail to excite a watery discharge from the intestines, and 
instead cause much irritation, with tenesmus, and slimy or bloody stools ; 
under these circumstances they must be discontinued; but after blister- 
ing the abdomen, or applying leeches to the region of the liver, or to the 
anus (319), and interposing a gentler but more searching aperient con- 
taining mercury, the useful operation of hydragogue purgatives may 
sometimes be again obtained. Similar means will often facilitate the 
operation of diuretics. Dr. O'Beirne has argued strongly in favor of 
bloodletting in dropsy, under the impression that, by relieving the pres- 
sure from cono;ested bloodvessels, it enables secretins; organs to act. 
{Dublin Journ. of Med. Sci. Nov. 1842.) Like most other writers on 
dropsy. Dr. O'Beirne does not seem to me sufficiently to regard the 
mixed character of the disease. 

397. The tendency of dropsy connected with diseased heart, kidneys, 
or liver to recur again and again, and become chronic, renders it need- 
ful to vary as much as possible the remedies employed, as well as to use 
means to support the strength. It is an important point in the treatment 
of such cases not to exhaust the powers of any secreting organ by tAvo 
long acting on it, and not to expend the efficacy of any one remedy by 
too long continuing its use. By employing sometimes diuretics, some- 
times purgatives, sometimes diaphoretics, and by aiding each of these 
by local depletion or derivants, or by stimulants and tonics, according to 
the temporary prevalence of vascular fulness and excitement, or the 
converse, much may often be effected to prolong life. It is in the appli- 
cation of these rules to the treatment of prolonged cases, that the skill 
and resources of the rational practitioner are most tried, and his supe- 
riority over the routinist is best proved. It is under these circumstances, 
too, advantageous to have at command a great variety of medicines, 
particularly diuretics, and to alternate them or vary them in order to in- 
crease or maintain their effect. Those that I have found most effectual 
are — combinations of mercury, squill, digitalis, and conium (not in acute 
albuminuria) ; combinations of decoction of broom, or pyrola umbellata, 
with nitrate and acetate of potass ; the juice or extract of taraxacum, 
with the same salts or bitartrate of potass, or with nitric acid (particularly 
in hepatic disease) ; infusion or tincture of digitalis, with iodide of po- 
tassium, and bitartrate of potass (in dropsy after scarlatina) ; the same, 
together with increasing doses of tincture of cantharides (in asthenic 
cases of albuminuria, after cupping to the loins and hydragogue purga- 
tives) ; ammonio-tartrate and ammonio-citrate of iron in Seltzer water 



218 PROXIMATE ELEMENTS OF DISEASE. 

(in asthenic dropsy) ; gin in cream of tartar beverage (imperial) ; com- 
pound spirit of juniper, spirit of nitric ether, with various others (in 
cases of debility). The latter stimulant diuretics have disappointed me 
more than any of the rest. 

398. When dropsical swellings have reached a certain amount of 
tension, diuretic and other remedies produce little or no eifect on them. 
The veins and lymphatics, whose office it is to remove these swellings, 
are too much compressed to be capable of absorbing. In the case of 
ascites, this pressure impedes the circulation through the kidneys and 
intestines, and their secretions are proportionally reduced (§ 159. Ex- 
tensive hydrothorax, and even ascites, in a similar way embarrass the 
functions of the lungs and heart. Anasarca, in its extreme degrees, 
sometimes impedes the circulation in the vessels of the.lower extremities, 
so far, as not only to prevent absorption, but even to cause the death of 
the parts ; hence gangrene of the legs is a common termination of incu- 
rable dropsy. The gangrene is commonly preceded by an erysipelatous 
kind of inflammation, which often seems to originate in some accidental 
scratch, or from the irritation of mechanical tension, or of the quality of 
the effused fluid. 

Now, in all these cases, the great expedient is to give exit to a portion 
of the fluid, by tapping or puncturing the parts which contain it. Thus 
the abdomen is tapped for ascites ; the chest for hydrothorax ; the scrotum 
for hydrocele ; the brain for hydrocephalus ; ovarian and other cysts, 
when they attain a large size; and the legs are acupunctured for anasarca. 
The relief afforded by these means is sometimes very remarkable, even 
when much fluid is left unremoved. In fact, the great utility of these 
operations seems to consist in the removal of an amount of pressure and 
distension that was seriously impeding the functions of the several parts. 
Accordingly we find, after these operations, not only a great mitigation 
of suffering, but a restoration of the functions of circulation, secretion, 
respiration, &c., which before were mechanically obstructed. After 
paracentesis, diuretic and other remedies regain their power, and con- 
tribute to reduce the remaining effusion; and the secretions being free, 
the patient is able to bear nourishing food and strengthening remedies, 
which previously would have increased the excitement and oppression. 

The usual indications for the use of these surgical resources are, an 
amount of dropsical effusion which seriously injures the functions of cir- 
culation, secretion, or respiration, other remedies having failed to give 
relief. Under such circumstances the operation should not be delayed. 
In puncturing the legs for anasarca, it is proper to bear in mind the 
tendency to low inflammation and gangrene ; and to avoid this, the skin 
and flesh should be injured as little as possible ; numerous punctures 
should be made with a fine needle, but not too close together ; and inas- 
much as there is more tendency to this result Avhere the circulation is 
weakest and most remote from the heart, it is better to avoid puncturing 
below the knees. 

Farther details on these subjects properly belong to special pathology, 
and would be out of place here. 



INFLAMMATION — NAME AND DEFINITION. 219 



SECTION yii. 

LOCAL HYPERiEMIA. EXCESS OF BLOOD IN A PART. 

III. WITH MOTION PARTLY INCREASED, PARTLY DIMINISHED = 

INFLAMMATION. 

DEFINITIONS. 

399. The morbid conditions connected with the quantity and motion 
of the blood hitherto described, have been pretty distinctly defined ; and 
we have been able to refer many phenomena of disease to them. We 
now come to one, the name of which is very familiar, and its frequency 
gives it so high an importance that it has always attracted the first 
attention of pathologists ; but although so commonly occurring, it is 
much more complicated in its nature than any of the morbid ele- 
ments previously considered ; in fact, it may be said almost to compre- 
hend them all, besides being a still farther deviation from the natural 
condition. 

The terms inflammation^ pJilegmasia, ixnd j^hlogo sis have been used, 
from a very remote period, to denote figuratively the heat, redness, and 
burning and painful sensations which commonly exist in inflamed parts. 
The occurrence of inflammation is so common, and its more prominent 
symptoms so familiar, that it has long been distinguished as a chief 
element of disease ; in fact it has, in a measure, engrossed the attention of 
pathologists so entirely, that other important elements have been almost 
overlooked ; and this oversight has not only retarded the advancement 
of our knowledge with regard to these other elements, but it has rendered 
the subject of inflammation itself less intelligible, by excluding the con- 
sideration of some of its component parts, and by keeping it in all its 
complexity and remoteness from the normal conditions of function and 
structure. We shall find that an acquaintance with the ultimate and 
proximate elements of disease, already considered in this work, is essen- 
tial to the proper understanding of the nature of inflammation ; for these 
form the connecting link between the natural properties of living textures, 
and their extreme variation in the state of inflammation. The patholo- 
gical definition given above to distinguish inflammation from the other 
varieties of hypersemia — too much hlood in a part with motion (of that 
blood) partly increased partly diminished — is easily demonstrated in the 
strong pulse of arteries leading to an inflamed part, and in the stagna- 
tion of much blood in the part. 

400. But besides this pathological definition, its outward characters 
may be briefly defined in the four signs, which from the time of Celsus 
have been considered distinctive of inflammation, redness, heat, pain, 
and swelling. These signs are sometimes produced by congestion (§ 
303), and by determination of blood (§ 333, &c.) ; but in a degree less 



220 PROXIMATE ELEMENTS OP DISEASE. 

marked, and for a time less continued, than in inflammation ; and altliougli 
there are cases and forms of inflammation in which it is not possible to 
detect all these marks, they may still be said to constitute its most ge- 
neral character. In common with other varieties of local hyperasmia, 
inflammation owes the sign of redness to the excess of blood in the part; 
but we shall find that this redness is heightened by a peculiar concen- 
tration of the particles in the inflamed vessels, which is also the cause 
of the peculiar results of the process. As in determination of blood, 
the heat and pain are in part due to the increased motion of the blood ; 
but in inflammation, they are exaggerated by the motion being opposed 
to obstruction. As with other forms of hypersemia, the swelling 
arises partly from the over-distension of the bloodvessels, and partly 
from effusions from them ; but in these effusions, inflammation differs 
from congestion and simple determination, departing still farther than 
these from the natural quantity and quality of the effused matters. 



401. JPredisjJOsition to inflammation has been already noticed under 
the head of predisposing causes of disease (chap. i. sect. 2). The cir- 
cumstances which render the body liable to inflammation, are those 
which especially affect the vascular system, whether these circumstances 
be the result of original conformation, as the sanguine temperament 
(§ 38) ; or whether they be the effect of previous disease (§ 31), of pre- 
sent disease (§ 34), or of external or internal causes in actual operation 
(§ 20, et seq. 30). Inasmuch as various circumstances, external or 
internal, tend, generally or locally, to impair the healthy tone and 
balance of the vascular system (§ 123), whilst muscular irritability 
(§ 112) and the quantity of the blood are not proportionately reduced 
(§ 195), so far they predispose to inflammation. Accordingly, we find 
persons prone to inflammation to be those whose circulation has been 
weakened or irregularly excited by previous disease, fatigue, confinement, 
impure air, or improper nourishment. But it will presently appear that 
predisposition to inflammation differs according to the nature of the 
cause which excites inflammation ; those most subject to inflammation 
from causes acting generally, suffering less than others from causes which 
act only locally. Thus, a depressed state of the whole vascular system 
favors the production of inflammation from causes acting generally (such 
as cold) ; whereas, an excited state of the vascular system favors the de- 
velopment of inflammation from local irritation. 

402. The concluding part of the last paragraph prepares us to divide 
the exciting causes of inflammation into those which act locally on the 
part which inflames, and those which act more generally on other parts. 
^J'lic operation of tlie first class is direct ; that of the second is indirect; 
tlicreforc, less certain, and more dependent on predisposition. 

The local exciting causes of inflammation comprehend irritants, me- 
chanical, chertiical, and vital. A grain of sand in the eye, a thorn in 
the true skin, and a. bruise or wound in the flesh are examples of me- 
chanical irritants, or sources of Irritation. Chemical irritants are those 



INFLAMMATION — CAUSES. 221 

which operate on living matter by strong chemical affinity, tending to 
alter or decompose it (§ 53) ; such are heat, strong acids, and alkalies, 
various corrosive salts, chlorine, iodine, &c. ; these act also on dead 
textures. Vital irritants are various agents whose irritating operation 
is not referable to any known chemical property, nor do they act on 
dead animal textures ; of this kind are cantharides, mustard, capsicum, 
and essential oils. In this last class must be included various animal 
and vegetable irritant poisons ; such as that of smallpox, and the venom 
of some noxious animals and plants, which act as local irritants, besides 
otherwise affecting the system. Various noxious matters sometimes 
generated in the living or recently dead body, are also capable of excit- 
ing inflammation when applied to an abraded surface (§ 258). Nay, the 
natural excretions of the body become most acrid irritants, when brought 
into contact with serous membranes ; thus urine, feces, and bile, effused 
in serous membranes, even in the smallest quantities, produce intense 
irritation and inflammation. 

Irritation and inflammation are sometimes caused by excrementitious 
matter retained in the blood, where the functions of the excernent organs 
are impaired (§§ 249, 251, 254). Local inflammations are also excited 
by certain poisons received into the system ; thus arsenic, even when 
applied to a wound, causes inflammation of the stomach and intestines ; 
mercury excites inflammation of the gums ; the poisons of smallpox, 
scarlatina, and measles, inflame the skin, throat, and air-passages ; that 
of syphilis, the periosteum, throat, skin, iris, &c. In these cases, there 
can be little doubt that inflammation is excited by the actual presence 
of the peculiar irritating matter in the parts which inflame, conveyed 
there in the blood ; and it is a leading character in the operation of these 
irritants which are conveyed through the blood, that it affects several 
parts, or a considerable portion of the body at once ; and frequently, 
the two sides of the body in a similar manner. This is observed in the 
eruptions of exanthematous and other skin diseases, in rheumatism, in 
syphilitic nodes, &c. (§ 259). 

403. The second class of causes exciting inflammation, those which 
operate indirectly, are of vei-y common occurrence ; and, although com- 
prising fewer agents, they as frequently produce diseases as the -more 
direct causes of irritation. They include those which first produce con- 
gestion, which, on the occurrence of subsequent reaction, is converted 
into inflammation. The most common of these causes is cold, which, 
both by its local operation (§ 76), and by its more general application 
(§ 77), may produce congestions (§§ 292, 296), which may pass into 
inflammation. Malaria, and the influences w^hich induce continued and 
eruptive fevers, as they produce congestions (§ 293), so they often lay 
the foundation of inflammations, which complicate the febrile affections 
excited by these causes. Inflammations sometimes arise out of the con- 
gestions caused by venous obstruction (§ 289) and gravitation. Thus 
pneumonia (with hepatization, and sometimes suppuration) frequently 
occurs in connection with disease of the heart, impeding the circulation; 
in adynamic fevers, and in the sinking which precedes death (§ 290). 
The congestions of the lungs, brain, and mucous membranes, that result 
from the application of various asphyxiating causes (§ 298), sometimes 



222 PROXIMATE ELEMENTS OF DISEASE. 

end in inflammations, "whicli become a chief source of danger after the 
restoration of the respiration (§§ 235, 243). 

404. Suppression of natural or habitual discharges, especially the 
catamenia, the sudden drying up of ulcers, and repulsion of cutaneous 
eruptions (§ 69), are recognized as causes of inflammation (§ 67). So far 
a,s the inflammation excited by these causes is in, or contiguous to, the 
parts previously affected, local irritation may have a share in producing 
it ; but where it is in distant parts, it probably results from a congestion 
or local determination of blood, which belongs to the second class of 
causes just specified. Very probably some of these causes of inflamma- 
tion have a twofold operation, that just specified (producing a local 
fulness), and that of local irritation by morbid matters introduced into 
the circulating mass of blood. Thus the visceral inflammations arising 
on the sudden healing of a suppurating wound may be promoted by 
local congestions resulting from the cessation of the purulent discharge; 
but their circumscribed character, and the uniform event to which they 
tend (suppuration), seem to indicate a morbid matter in the circulating 
blood, as the exciting cause of these inflammations, and microscopical 
researches have confirmed this inference. The same remark will apply 
to the inflammations of the skin, fauces, and mucous membranes in 
scarlatina, measles, and smallpox, the follicular enteritis of typhus,^ 
and the visceral complications of erysipelas, and other specific febrile 
affections. In all these, besides a general tendency to internal conges- 
tions, we seem to trace the irritating operation of a morbid poison on 
particular parts. 

405. We have noticed that sthenic hemorrhages (§ 363) and fluxes 
(§ 393), if too speedily checked without sufficient reduction of the circu- 
lation, are apt to pass into inflammation. So likewise determination of 
blood, if it be long continued, may issue in inflammation (§ 340). The 
causes which excite determination of blood, when applied in a greater 
degree, or for a longer time, excite inflammation. 

406. Before we proceed to examine into the nature of inflammation, 
we may properly inquire what is the mode of the operation of its causes. 
It is generally assumed that the first movement of inflammation, as of 
all pathological processes, is in the nerves ; but this is by no means 
proved. That some causes of inflammation (irritants) operate first on 

> I have observed an extraordinary development and inflammation of the isolated and 
grouped glands of the intestines in the bodies of persons poisoned with arsenic. Their 
enlargement in epidemic cholera, and in the severe form of spoi\adic cholera, diarrhoea, 
and dysentery, caused by putrid effluvia, is well known. Are these glands excretory 
organs for the elimination of poisonous or noxious matters from the system ? and in typhus 
fever, do they become inflamed and ulcerated by the continued operation of the poison in 
the exercise of this function ? The favorable influence of moderate diarrhoea in fever, the 
uncommon fetor of the stools, the general relation between the duration of the fever and 
the affection of these follicles, the salutary operation of mild mercurial remedies, which 
promote their secretion, and other facts that might be adduced, give so much countenance 
to this question, as to make it worthy of attention. 

The preceding surmise, put forth in tlie first edition of this work, has received corrobo- 
ration from numerous facts wliich I have subsequently observed, and it seems to me to 
indicate tlic true cause of the intestinal complication in fevers and other diseases induced 
by a morbid y)oison in tlie system. Dr. Carpenter has recently advocated this opinion, 
and farther applied it to account for the fetid and colliquative diarrhoea which often occurs 
in states of mucli depression. — [Jlumnn I'liysiolor/y, [p. 037, '5th Am. Ed.]) 



INFLAMMATION — CAUSES. 223 

the nerves, is probable from the following considerations: 1. Their 
ac.tion on the sensitive nerves is felt long before inflammation begins ; 
thus the prick of a thorn in the skin, the smarting of caustic on a wound, 
the pain of the sting of an insect, are felt instantaneously ; there is first 
nervous irritation ; inflammation follows after. 2. The irritation is 
sometimes transferred to other parts by sympathy, of which nerves are. 
the channels ; thus strong irritants in the nostrils may cause inflamma- 
tion of the conjunctiva, a carious tooth or a diseased bone may irritate 
and inflame parts which are not contiguous to it. 3. An injur^ to a 
nerve is sometimes followed by inflammation in parts connected with 
this nerve. Thus paralyzed limbs are liable to become inflamed. Lal- 
lemand relates a case in which a ligature, involving the right brachial 
plexus, was followed by inflammation and suppuration in the opposite 
hemisphere of the brain. 

407. On the other hand, the following arguments may be adduced to 
show that the nerves are not essentially the seat of the first part of the 
process of inflammation. 1. Some of the causes of inflammation (the 
majority of those inducing internal inflammation) produce on the nerves 
or nervous system no known primary efl'ect which resembles that of 
other causes of inflammation (irritants) ; thus inflammations excited by 
cold are often preceded by no marked nervous disturbance ; whereas 
the strongest impressions of cold on this system are frequently not fol- 
lowed by inflammation (§ 77). 2. Inflammations often originate in con- 
gestions (§ 403), and in the sudden suppression of hemorrhages and other 
discharges (§ 4()5), without the occurrence of any symptoms referable 
to the nerves ; hence inflammations thus arising may escape detection, 
and are called latent. 3. Persons in whom nervous properties are most 
developed (§§ 126, 152, 156) are not those most susceptible of inflamma- 
tion ; and all varieties of nervous excitement are sometimes manifest in 
the highest degree without any inflammation ensuing. Even where pain 
and other nervous symptoms are excessive, and are the result of mecha- 
nical or chemical injuries (such as crushed limbs, extensive burns, &c.), 
inflammation sometimes does not follow ; and this has led surgeons long 
to distinguish between irritation and inflammation. 4. Inflammation 
readily occurs in parts the nerves of which are paralyzed or have been 
divided.^ 

408. Seeing, then, that inflammation is frequently excited without 
any obvious aff'ection of the nerves, and is often not excited when nerv- 
ous irritation is most intense, it may fairly be inferred that an impres- 
sion on the nerves is not an essential part of the first process of inflam- 
mation. That the nerves are concerned in many ulterior phenomena of 
inflammation, and in its extension, is fully admitted ; and in the case of 
excitement of inflammation by irritation, the primary operation of the 
exciting cause on the nerves has been already pointed out (§ 406). So 

^ It is maintained by Dr. Copland and others that, in these cases, branches of the gan- 
glionic system distributed on the coats of the bloodvessels are the first subjects of excite- 
ment. This hypothesis gives no aid in the explanation of the phenomena, because no- 
thing is definitely known as to the properties communicated by ganglionic nerves. Before 
the "influence of the ganglionic system" can be employed as an element in pathology, its 
existence must be proved, and its properties defined in physiology; this has not been done. 



224 PROXIMATE ELEMENTS OF DISEASE. 

far as is known, the bloodvessels are the essential seat of the whole pro- 
cess of inflammation ; and although some of the exciting causes of iji- 
flammation (§ 402, irritants) act on the nerves as well, yet others 
(§ 403, as cold) operate chiefly and essentially only on the bloodvessels. 
Hence we find that the causes predisposing to inflammation (§ 401) are 
circumstances chiefly affecting the vascular system. A review of the 
exciting causes of inflammation (§§ 402, 405) will show that in their 
mode of operation on the bloodvessels they may be divided into two 
classes : 1, those that cause determination of blood (§§ 322-324) ; and, 
2, those that produce congestion (§§ 290-299). The former class com- 
prehends all irritants (§ 402) ; the latter class includes cold and other 
agents, which directly produce congestion (§§ 403, 405). We have 
several times had occasion to mention that determination of blood, when 
exceeding certain limits, is apt to pass into inflammation (§ 340) ; and 
that local congestions are liable to be converted into inflammation 
(§§ 292, 293, 306). 



PHENOMENA AND NATURE OF INFLAMMATION. 

409. Having noticed the causes of inflammation, and traced their es- 
sential operation to be on the bloodvessels and their contents, we have 
next to inquire what is the character of their operation on the vessels, 
and what phenomena it develops. 

That the bloodvessels are enlarged in an inflamed part is very obvious 
from the increased redness manifest to the naked eye. But in what re- 
spect does inflammation differ from congestion, in which also the vessels 
are enlarged? It differs not only in the accompanying symptoms and 
in its products, but also in the observed condition of the vessels of the 
part. Thus, besides greater pain and heat in an inflamed part, and 
earlier and more abundant effusions into or from it, the more florid hue 
of redness, the strong beating of the arteries leading to the part, and 
augmented quantity of blood flowing from its veins, clearly indicate that 
there is increased motion of the blood, instead of diminished motion, as 
in congestion (§ 287). 

Common observation of the pulse of arteries leading to inflamed parts 
would sufiice to show that there is determination of blood to them ; and 
some experiments, performed by Dr. Alison and others, have directly 
proved that these arteries are enlarged.^ It w^as found that the arteries 
leading to an inflamed limb in a horse were considerably larger than those 
of the sound limb. John Hunter had arrived at the same conclusion 
from experiments on the ears of a rabbit. Now, this enlargement has 
been before traced to diminished tonicity in the affected arteries, and this 
was found to be the chief instrument in causing determination of blood 
(§§ 326, ;!27). 

That the motion of the blood is increased through an inflamed part, is 
distinctly proved by the observation of Mr. Lawrence; venesection being 
performed at the same time, and in the same manner, in both arms of a 

' Trans, of British Association, 1835. 



INFLAMMATION — NATURE AND PHENOMENA. 225 

patient who had an inflammation in one hand, a much greater quantity 
of blood flowed from the vein of the arm of the inflamed hand than from 
that of the other arm. 

410. It is certain, both from the preceding facts, and from direct ob- 
servation under the microscope, that determination of blood is present in 
inflammation. The vessels in the vicinity of the inflamed part are the 
channels of an increased flow, there being a flux of blood to the whole 
inflamed part, and through some of its vessels. But if this were all, 
there would be no distinction between determination of blood and in- 
flammation ; yet the greater redness and swelling, and peculiar character 
of the efi'usion, point out that inflammation is not mere determination. 
Microscopic research has established one great point of diff'erence. The 
observations of Thomson, Hastings, Kaltenbrunner, and Marshall Hall, 
have long clearly proved that there is more or less obstruction to the pas- 
sage of the blood in the vessels most inflamed. Thus in the frog's web, 
when a part inflames from local irritation, the blood is seen to move more 
slowly in the part most irritated, and gradually accumulating in the ves- 
sels, renders them larger, redder, and more tortuous, until the motion 
ceases altogether in them, w^hilst neighboring vessels are still the channel 
of an increased current. A chief point, then, in which inflammation dif- 
fers from determination of blood, is in the retarded or arrested flow of 
blood in some of the vessels. This answers to the definition which we 
have given of inflammation; too much blood in a fart, ivitJi motion (of 
that blood) partly increased, partly diminished (§ 399). 

411. The question now naturally arises. What is the cause of the 
obstructed or retarded flow of blood through an inflamed part ? This 
has ever been the chief difiiculty in the pathology of inflammation; and 
it is especially to solve this that various hypotheses have been framed. 
Thus Cullen supposed a spasm of the extreme vessels to be the cause of 
obstruction, and therefore the proximate cause (§ 13) of inflammation. 
Dr. Wilson Philip ascribes the same obstruction to a weakness of the 
capillaries, which he presumes to incapacitate these vessels from trans- 
mitting the blood. John Hunter considered that there is something 
more active and vital in the enlargement of inflamed vessels, and he 
applied to it the term " active dilatation." The analogous expressions, 
''vital turgescence," "turgor vitalis," "inflammatory erection," used 
by Kaltenbrunner and other German writers, imply a similar notion. 

The hypothesis of Cullen is quite inconsistent with direct observation, 
the extreme vessels being seen, under the microscope, to be in a state 
of dilatation, not of spasm. This observation corresponds better with 
the idea of Dr. W. Philip, which was, indeed, founded upon it; but it 
has been objected by Dr. Marshall Hall, and others, that the capillaries, 
by their contraction, do not aid in the circulation of the blood, and that 
their " debility," therefore, cannot be a sufficient cause for interrupted 
passage of blood through them. The words used by Hunter scarcely 
convey any explanatory meaning. They may be interpreted to assume 
the existence of a self-expansive power in the vessels, which power is 
supposed to act in inflammation, as well as in natural formative or plas- 
tic processes in the animal body. But the existence of such a power is 
quite at variance with all that is known of animal physics. A part may 
15 



226 PROXIMATE ELEMENTS OF DISEASE. 

be expanded by elasticity, or by the injection or retention of fluid in it, 
but no direct vital expansile power has been ever proved to exist. The 
apparently active expansion of the heart in its diastole, may be ascribed 
to the natural elasticity of the organ, and the increasing weight of its 
contents, suddenly enlarging its size on the cessation of its antagonizing 
systole; neither its structure nor its mode of action countenances the 
notion of a vital dilating power. 

412. Haller, and some of his followers, ascribed the circulation of 
the blood, in part, to certain supposed properties of vital attraction and 
repulsion, by which the blood is drawn into, or repelled from, particular 
parts, independently of all motion of the living solids. These opinions 
have been recently advocated, with much ability, by Dr. Alison and 
some of his followers, who consider changes in these assumed vital at- 
tractions and repulsions, to be the chief elements in the process of in- 
flammation, as well as in other pathological conditions in which the 
blood and its vessels are mainly concerned.^ This hypothesis needs the 
most ample proof before it can be received. It assumes the existence, 
in the fluids as well as in the solids of the living body, of properties as 

1 See Alison's Outlines of Pathology and Practice of Medicine. Several of Dr. Ali- 
son's arguments in favor of the existence of "vital attractions and repulsions," are founded 
on certain physiological facts, w^hich he coiisiders inexplicable in any other view. It belongs 
properly to works on physiology to discuss these matters ; but I must own that none of 
these arguments seem to me to be satisfactory. The motion of the sap in the chara and other 
vegetables, may be well explained on the principle of exosmosis and endosmosis. A fluid 
of lower density (water), physically tends to penetrate and pass into membranous tubes, 
containing a liquid of greater density (sap) ; that which begins a flow into the tubes, 
may sustain it in continued current through them, so long as the difference in density sub- 
sists between the water and sap. A similar principle doubtless aids, in many cases, the 
motion of fluids in the animal body ; but many motions of fluids observed in animals (as in 
the air-tubes, genito-urinary passages, &c. ) have been traced to the vibrations of cilia, and 
are no proof of the existence of vital attractions and repulsions. 

It is said, that, when an artery is tied, the blood ceases to run in the open part of it, 
and passes away by adjoining branches, which become enlarged in proportion, whilst the 
tied portion becomes empty. It has been supposed that the blood here spontaneously leaves 
the part of the artery through which there is no passage. I demur to the correctness of 
the statement, and still more to the explanation. Every one who has witnessed great sur- 
jcical operations, must have noticed the strong pulsation above the ligatiu-e of tied arteries ; 
and the occasional occurrence of secondary hemorrhage shows that the blood has no in- 
herent disposition to pass in a new direction. No doubt, the artery ceases to receive blood 
into its tied portion ; but this is because either a coagulum is formed where a current can- 
not pass, or the tonicity of this portion effects the contraction of the tube, the force of the 
circulation being diverted into the contiguous enlarged branches. Here is no proof of any 
self-motory and self-directing power in the blood. I have before stated, that all my own 
microscopic observations have failed to detect in the blood any spontaneous motions, inde- 
pendent of contractions of the solids, or of currents, caused by ciliary motion, exosmosis 
and endosmosis, and such physical influences. The oscillatory motion said to have been 
seen by llaller and Kaltcnbrunner in the small bloodvessels of inflamed parts, "even after 
the heart is at rest," may, perhaps, be ascribed to the tonic contraction of the arteries, 
which, althougli gradual in itself, is often seen to act by jerks on partially obstructed 
vessels. A simibir oscillatory movement is sometimes communicated to capillary vessels by 
the quivering contraction of adjoining muscles. Another observation of Haller mentioned 
by Dr. Alison, that of "blood escaping fi'om vessels between the layers of a living mem- 
brane, and nevertheless pursuing its course in a regular stream for a time, even against 
the influence of gravity," may l)e fairly referred to the vis d tercjo from the open vessel. 
In the fluids of such a nicely adjusted liydraulic apparatus as the vascular system of ani- 
mals, and even vegetables, it is surprising liow readily motions may be produced by 
various physical causes ; and when these motions are magnified by the microscope, it is not 
Avon'lcrful that tliey should have been mistaken for vital movements of the fluids themselves. 



INFLAMMATION — NATURE AND PHENOMENA. 227 

distinctive, and as peculiarly vital, as that of contractility or sensibility. 
It ascribes to these fluids and solids powers of attraction and repulsion 
at sensible distances, like the attractions and repulsions of electricity, 
magnetism, or gravitation, yet distinct from all these, and sometimes op- 
posed to them. It attributes to the living body a new physical power, 
and almost a discerning intelligence in the exercise of that power. Now, 
before the existence of such a power can be admitted, it must be proved 
that the phenomena of living structures are not, and cannot be, explained 
through any known vital or physical agencies. We have already ad- 
duced and referred to arguments and observations, to show that the 
'known physical and vital properties of the living body will account for 
the chief phenomena of health and disease, without assuming the existence 
of any forces of a mysterious character ; and we have now to consider 
whether the same thing may be done with regard to inflammation. If 
we succeed in explaining the nature and efi'ects of inflammation by a re- 
ference to ascertained properties, it will be needless and unphilosophical 
to assume the existence of others, which are mysterious and unknown. 
We do not pt-etend to propose these explanations as complete or certain, 
but as the best that we can devise in the present state of science, and 
the most consistent with well-established facts ; and it is very satisfactory 
to observe that the discoveries in chemical physiology made since the 
first edition of this work was Avritten, so far from invalidating these views 
on the nature of inflammation and its results, go far to confirm and ex- 
tend them. 

> 413. We have before stated (§ 408) that inflammation may originate 
either in determination of blood, or in congestion ; and we now proceed 
to show that inflammation essentially comprises both these morbid ele- 
ments. The mode in which the process of inflammation has been chiefly 
studied, is by observing under the microscope the eff"ect of irritants on 
the frog's web. It must be remembered, however, that this is only one 
mode in which inflammation may begin, and we shall afterwards find 
that cold-blooded animals fail to show some of the most remarkable re- 
sults of inflammation. 

The efl'ect of weak irritants on the vessels of the frog's web has been 
described before (§§ 294, 326). We then found that irritation may cause 
first determination of blood, then congestion, these results being depend- 
ent on an enlargement respectively of the arteries and of the veins and 
capillaries. But if a strong irritant (as a grain of capsicum, or a minute 
globule of essential oiP) be applied to the web of a frog, all the blood- 
vessels speedily become enlarged ; those most irritated are very large 
and red, and the blood in them is stagnant and coagulated ; contiguous 
vessels are also very large, but less red, and the motion of the blood in 
them is slow, and often in pulses or oscillations ; whilst in vessels be- • 
yond, the enlargement of the capillaries is less considerable, but that of 
the arteries is obvious, and the current of blood is very rapid. 

Now, it is obviously the stagnation or tardy motion of the blood in the 
most enlarged capillaries, in the midst of surrounding increased flow, 
that most characterizes inflammation ; and we have still to inquire what 

^ These are preferred because they produce no chemical change in the parts. 



228 PROXIMATE ELEMENTS OF DISEASE. 

is the cause of the stagnation. This cause must be either in the vessels, 
or in their blood, or in both. The latter we shall find to be the true 
case. 

414. We have already pointed out (§ 300) that atony and flaccidity 
of bloodvessels may become a cause of impediment to a current through 
them, not by preventing these vessels from actively contracting on their 
contents (for they have no such power), but by removing that tone by 
which the vessels maintain the caliber and the tension best calculated to 
transmit onwards the force of the current. Vessels thus weak and in- 
elastic, instead of equably conveying the current, become distended, 
lengthened, and tortuous in receiving it ; and by their very mass, as well 
as by their inelasticity, they partly break the force of the current, and 
partl}^ turn it into other channels. The mode in which this results in 
inflammation will be better understood, if we review other local modifi- 
cations of the circulation in comparison with it. 

In determination of blood, the arteries are enlarged, and so are the 
capillaries in due proportion ; the circulation is therefore equally increased. 
In congestion, the capillaries are enlarged, without any increase of the 
arteries ; the motion is therefore impaired ; but still, being gentle, it may 
difiuse itself through the mass, which moves slowly. But if to con- 
gested capillaries there be added the increased and abrupt force of the 
current from enlarged arteries, or if to determination of blood (enlarged 
arteries) (§ 326) an atonic congestion of the capillaries be joined, the 
propulsive power of the current will be impaired. As in the experiment 
with the intestine (§ 300), the blood will pulsate or oscillate in the dis- 
tended vessels rather than pass through them ; and the main current will 
pass through collateral anastomosing channels, which become the seat 
of simple determination or increased flow. This is just the state of 
things in the incipient stage of inflammation ; and if either the capilla- 
ries do not speedily recover their tone, or the arteries do not contract, 
the blood in part becomes stagnant, its particles adhere to each other, 
and to the walls of the vessel, and the obstruction is confirmed. The 
arterial portions of some of the obstructed capillaries are still open, and 
exposed to pulsative force from the supplying arteries, which continues 
to strain their coats, and cause an oscillatory motion of their blood-par- 
ticles, but no passage through them. Such are the phenomena which 
we see under the microscope. 

It may, then, be fairly inferred, that one cause of the stagnation or 
retardation of the blood in an inflamed part, is a weak inelastic state 
of the capillary vessels;^ such, in fact, as exists in cases of atonic con- 
gestion ; and on referring to the causes of inflammation (§ 404), it may 
be perceived that many of them act by first producing congestion. Nay, 

' It may, pcrliaps, be objected, that I have supposed a similar atonic state of the arte- 
ries to be the cause of an increased flow tlirough them, and to be the phj'^sical cause of 
determination of bhjod. liut tliis is no objection. The arteries, as compared with the 
capillaries, are few in number; their current is rapid ; tliey are exposed to the pressure of 
a vis (i (erf/o, which maintains the velocity of their current, whatsoever may be their cali- 
V)er; when their coats lose some of their tone, this pressure of blood into them stretches 
them to tonf^ion, and they thus admit an augmented force and volume. In capillaries, on 
the other hand, the cuiTcnt is so much subdivided and straitened that it is easily disturbed, 
and tlie motion, naturaliy tardy, is readily arrested. 



INFLAMMATION — NATURE AND PHENOMENA. 229 

we have found (§ 294) that even irritants, in some measure, operate in 
the same way. "The continued application of stimuli to a part is some- 
times followed not by inflammation, but by congestion. This especially 
happens in the liver, a chiefly venous organ ; but it occurs also in other 
parts. It might be supposed that the stimuli act by exhausting the 
contractility of the small vessels, and thus leaving them weakened and 

distended by their contents 

But on the application of a strong stimulant, such as a minute particle 
of essential oil, the previous arterial contraction is not apparent, and 
the enlargement is speedy and obvious, causing extreme rapidity of mo- 
tion and enlargement in all the vessels. In a few minutes, the size of 
the arteries begins to diminish, and with it the motion in the capillaries 
beyond them. Many of the capillaries still retain their enlarged di- 
mensions ; in them' the motion is most sluggish, and, in some parts, 
ceases altogether."^ 

415. But it is very certain that the obstruction, and much of the other 
features of inflammation, are generally dependent on changes which 
take place in the blood within the inflamed vessels. J. Hunter did not 
overlook this ; and, besides describing the coagulation of the blood in 
the most inflamed vessels, he mentions the adhesion of fibrine to their 
interior. The coagulation of the blood in the inflamed vessels was also 
noticed by Gendrin and others ; and Dr. Marshall Hall attributed the 
obstruction of the vessels in inflammation to the adhesion of blood- 
globules to the walls of the vessels. It appeared to me that microscopic 
observation ought to be directed to this point more specially than had 
hitherto been done ; and in 1841, I made many careful examinations of 
the early stage of inflammation in the frog's web. Some of the results 
were published in the Medical Gazette of July of that year ; and as they 
have been confirmed by several other observers, it may be proper to 
describe them. 

Poisseuille, in his observations with regard to the motionless layer of 
serum which intervenes between the moving blood and the walls of blood- 
vessels, had noticed that the blood-particles sometimes get into this still 
layer, and either remain fixed there, or move onwards more slowly than 
the rest of the blood. In repeating this observation, Mr. Toynbee and 
myself remarked, that it was not the red particle, or elliptical blood- 
disks, that thus adhered to, or slowly rolled along the sides of the ves- 
sels, but the white or colorless globules (§ 212), called by Mliller, lymph- 
globules. (The following description is taken from my G-ulstoyiian Lec- 
tures^ of 1841) : " I have never seen a solitary elliptical disk adhering to 
the sides of a vessel ; and whenever one was arrested in its course, it was 
from its becoming hitched by one or more of the adherent round globules. 
But what appeared to me most remarkable with regard to these white 
globules, was the great difi'erence in their number under difi'erent cir- 
cumstances. In young frogs, and in those much subjected to experi- 
ment, they are always present in great numbers ; but in healthy adult 
frogs placed under the microscope with as little handling of the web as 
possible, there were comparatively few to be seen. I have watched, for 

i Extracted from the Author's Gulstonian Lectures for 1841, Med. Gaz. July 16, 1841. 



230 PROXIMATE ELEMENTS OF DISEASE. 

ten minutes at a time, without seeing one ; the motionless layer was 
very thin but clear, and all the blood-particles in the larger vessels 
seemed to move at the same rate of speed." It is under these circum- 
stances that the effect of irritation or mechanical injury was best seen. 
*' By pressure of the finger on the web, partial stagnation was produced 
in many of the vessels ; and when this yielded to the returning current 
the walls of the vessel were seen studded with the white globules ; whilst 
many others of the same kind rolled over them slowly in the direction 
of the current. I have before mentioned (§ 294), that a similar result 
ensued, after the web had been stimulated by capsicum or an aromatic 
water. Even in the rapid flow of blood following these applications, 
minute globules could be seen creeping slowly along the transparent out- 
line of the larger vessels ; and as the arteries contracted, and the flow 
through the other vessels became less rapid, the number of these glo- 
bules increased, their motion became slower, and many adhered to the 
sides of the vessels. If the stimulus used was rather strong or long- 
applied, the number of sticking globules was so great as to prevent the 
red particles from passing : and these, becoming impacted in increased 
numbers, gave to the obstructed vessels a uniform and deeper red color. 
When the stimulation was moderate, and equally applied to the web, 
the stagnation usually took place first in some of those anastomosing 
veins in which the current is naturally slow, and varying in direction ; 
but when a stronger stimulus (as an essential oil) was used, the stagna- 
tion speedily ensued at the point of its application ; in fact, unless very 
minute quantities were employed, the stagnation was almost immediate 
and extensive."^ 

416. I have varied these observations in a great many ways, and have 

1 Med. Gaz. Julj 23, 1841. It -^as not until after these observations were made that 
I became acquainted with similar ones, previously published by Mr. Addison, of Great 
Malvern, in tlie Med. Gaz. of Jan. 29 of the same year. The folloT\-ing description is 
.given by Mr. Addison : "In the frog's Aveb, two days after the application of salt, in some 
of the larger capillaries or smaller veins, there are a great number of globules. No. 3" 
(lymph globules) ; "and it is quite extraordinary to observe the difference in movement 
between these round speckled globules and the oval ones ; the blood-globules pass in a 
continued stream, while in the same fluid, in the same vessel, are a great multitude of other 
(lymph No. 3) globules, which do not move, or do so very sluggishly ; every now and then 
they move slowlj-, apparently urged on by the repeated knocks they receive from the 
blood-globules. It would appear that, after the capillary vessels have been acted on by 
the salt, the round (lymph) globules accumulate in an unusual manner, and the blood- 
globules repeatedly slide over and knock against them. In some of the vessels there is 
a rapid stream of blood in the centre, whilst at the circumference there are nvAwj station- 
ary, round, spotted globules, which do not obey the impulse which urges the stream of 
blood, but remain or move on sloAvly by little starts, at uncertain intervals, and with un- 
equal pace." This account corresponds very exactly with what I have m3'Self observed : 
but I sliould not consider the experiment so conclusive with regard to inflammation, inas- 
niucl) as tlie cliemical action of tlie salt might have been concerned in the production of 
the lympli-globules, as salt seems to generate granules in the blood-liquor. In my observ- 
ations, I was careful to use no irritant wliich has any known chemical action on the 
blood. The greater j)revalcncc of lyiiipli-globules in the motionless layer had been noticed 
by Wagner and others, ami their moie aljundaiit production in an inflamed part has been 
mentioned ))y Mr. Gulliver. The presence of the pale corpuscles in inflamed vessels has 
ll been questioned ]>y Dr. Hughes IJennett, who hints that Mr. Addison and myself may have 

J mistaken for tliem epitlieliuni cells lining the vessels ; but the plain description above given, 

' and which I have repeated]}' verified, admits of no such interpretation. The granular 

: corpuscles may be distinctly seen to roll sluggishly and with a draglail befor© they stop ; 

i which they obviously do l)y adhesion to the interior of the vessel. I cannot understand 

i why Dr. Bennett has failed to sec so clear an appearance. 

11 



INFLAMMATION — NATURE AND PHENOMENA. 231 

always found considerable or continued irritation of the vessels in the 
frog's web to be attended with the appearance and adhesion of the color- 
less globules ; and that when the irritant is at all strong, or frequently 
applied, many vessels become totally obstructed, appear larger and red- 
der in consequence of the accumulation of red particles in them (the 
blood-liquor having passed on), and exhibit to the naked eye all the ap- 
pearance of inflammatory injection. The chief cause of obstruction 
seems to be comprised in the two circumstances : the increased produc- 
tion of the white globules, and their remarkable disposition to adhere to 
the walls of the vessels and to one another ; each of these circumstances 
must now be noticed. 

The origin of the white or lymph corpuscles (§ 195), seen in the blood, 
is involved in some doubt. They are distinctly spheroidal bodies, of a 
gelatinous consistence, and composed of granules, some of which have 
the appearance of nuclei. According to Mr, Addison,^ they are in- 
vested by a delicate membrane, constituting a compound granular cell, 
which slowly by the action of water, more promptly by the operation of 
solution of potass, bursts and discharges granules and rciolecules. In this 
respect, they differ from the blood-disks, Avhich are speedily burst, and are 
almost dissolved by either of these fluids. They appear to consist of 
fibrine, or rather deutoxide of proteine; and, as in the case of other 
granular bodies formed in an albuminous fluid, each granule probably has 
a central nucleus or molecule of fat, which makes their specific gravity 
lower than that of the red particles ; hence their disposition to collect in 
the buffy coat of inflamed blood. The increased number of these bodies 
within the vessels of an inflamed part has been observed by Mr. Addi- 
son as well as by myself; and from careful comparison with those in 
uninflamed vessels, I infer that this increase is due not merely to their 
being arrested in their transit through the inflamed vessels, but to their 
being actually formed in greater numbers.^ Nor is it difficult to explain 
their production, if we consider the combination of causes which are ope- 
rating in inflamed vessels. The blood-liquid is highly charged with pro- 
teine, which needs only a farther process of oxidation to assume the 
solid form of the deutoxide ; this process is supplied by the free current 
of arterial blood (determination) which rushes into the obstructed por- 
tions, and brings the red particles, the oxygen-carriers, in such forcible 
contact with blood-liquor as favors the transfer of oxygen to the pro- 
teine contained in it. As the proteine becomes oxidized, it consolidates 
in a granular form, and the more readily around the oily molecules 
always diffused through the blood-liquid ; " and these form the nucleoli 
visible in the larger granules. But the granules also cohere in clusters, 
and form the pale corpuscles of various sizes which appear adhering to 

' Trans, of Provincial Med. and Surg. Assoc. 1843, p. 240. 

2 This statement, which corresponds with that given previously (| 415), has been made 
the subject of animadversion and inconsiderate ridicule by parties who find it easier to cri- 
ticize observations which oppose their own notions, than to investigate the matter carefuUy 
themselves. It will be perceived that the pathology of the blood in inflammation indubita- 
bly proves that the pale corpuscles are increased not in a part only, but in the whole blood ; 
whereas, if they were only accumulated in the inflamed part, there would be fewer than 
usual in the blood at large. In the former edition, I stated the fact ; the advance of animal 
chemistry enables me now to offer its explanation. 



232 



PROXIMATE ELEMENTS OF DISEASE. 



and creeping along the sides of irritated vessels.^ This explanation 
corresponds with the sudden manner in which they appear in such num- 
bers in the vessels of the frog's web, not only after continued irritation, 
but after momentary rough handling or squeezing the web, which par- 
tially obstructs the vessels and directs the force of the arterial cur- 
rent on their contents ; the walls then appear studded with adherent 
and creeping corpuscles ; but as the impediment and the determination 
are not here permanent, these corpuscles are soon swept away and dis- 
appear. In inflamed vessels, on the other hand, they are a constant 
element, and, as we shall find, are chiefly instrumental in producing its 
phenomena and results. Their abundance in inflamed blood has been 
noticed by Gendrin, Gulliver, Addison, and others. 

417. We have next to notice the peculiar disposition of the pale cor- 

^ The accompanying diagram exhibits the appearance of a small portion of the capilla- 
ries of a frog's web after the application of a grain of capsicum. The elliptical blood-disks 
(b) are running in the axis of the vessel, which is much narrowed by white globules adher- 
ing to the walls, or only slowly rolling along them. These globules are speckled with nu- 
clei or granules, refract the light strongly, and when rolled on by the current, some of them 
become pear-shaped from their sticking to the vessel, thus forming a kind of dragging tail, 
seen very well in those marked [a] ; on altering the focus, similar globules may be seen ad- 
Fig. 10. 




hering to the other parts of the vessel. The shaded portion (c) is totally obstructed with 
•white and red particles, so impacted togetlier as to form a homogeneous red mass. In such 
a case I have often seen tlic particles at (d) cxliibit a pulsating or oscillatory motion (cor- 
responding with the action of the heart) ; and tliis, after a time, succeeds in breaking down 
the obstructing mass, wliicli passes away in clots, leaving the vessel (r) studded with pale 
corpuscles like the other; and this result is observed whetlier the obstruction has taken 
place suddenly, or slowly, showing that in either case these corpuscles are present. 



INFLAMMATION — NATURE AND PHENOMENA. 233 

piiscles to adhere to the avails of the vessels. This disposition has been 
ascribed to a vital attraction ; but although it is made subservient to the 
purposes of life and organization, it appears to me to be the mere result 
of the physical property of adhesiveness common to soft solids of gluti- 
nous material. The same property is shown in the field of the micro- 
scope, in the manner in which the pale corpuscles stick to the glass, 
whilst the red particles float in the liquid. It has, however, been ob- 
jected that in blood drawn, " the white corpuscles do not show any tend- 
ency to adhere to each other or to the red particles, which they natu- 
rally would do if their surfaces were adhesive enough to cause them to 
stick to the walls of the vessels."^ But this objection has no force when 
it is considered that the white corpuscles do cohere most readily when 
brought into contact ; and the reason why they appear separate in the 
field of the microscope, is because they at once stick to the glass, and 
are not free to move and congregate like the red particles. They do 
not usually adhere to the red particles because they are smooth loose 
sacs of fluid, the exosmotic properties of which are intended to keep them 
as loose and free as possible, so that they are carried with every motion 
of the current.^ But there are circumstances in which the red and pale 
corpuscles do cohere together ; and that is when their compression 
within the vessels prevents exosmosis ; so also there is a condition of 
the walls of the bloodvessels in which the pale corpuscles adhere little 
or not at all to them ; and that is when endosmosis through their walls 
is as free as exosmosis, in the absence of all distension of the vessel ; 
and this explains why, in the instance before mentioned, the pale cor- 
puscles which adhered, become detached as the circulation is restored 
to its natural state. 

The ordinary pale corpuscles of the blood certainly have an investing 
cell-wall, as first shown by Mr. Addison ; but those recently formed in 
inflamed vessels do not appear to me to be so invested, and hence their 
more adhesive property. But they soon acquire this covering, which 
seems to be nothing more than an outer coating of coagulated albumen 
or deutoxide of proteine more solid than the rest of the corpuscle. In 
like manner, globules of milk, oil, &c., acquire in serum an albuminous 
coating, as observed by Ascherson, Donnd, and Gulliver. I am aware 
that the expression of this opinion will not be favorably received by those 
who uphold the doctrine of cell-life as fundamental to all processes of 
organization ; but we have already noticed facts in regard to the organ- 
ization of fibrine (§§ 211, 212) which show that this doctrine is by no 
means of universal application. 

418. Except as the chief vehicles of oxygen, the red particles are less 
concerned than the white corpuscles, in the commencement of the ob- 
struction of inflamed vessels; they are seen still free, although twisting 
and struggling between the accumulating white corpuscles ; and so long 
as they so pass, they show no disposition to cohere or form rouleaux ;- 

^ British and Foreign Medical Review, July, 1844, p. 107. 

^ These physical difterences may be rudely illustrated by a clot of adhesive jelly and a 
thin bladder containing "vvater; the jelly adheres to any plain or concave surface, so that 
it may not be detached by inversion ; the bladder rolls readily when the surface is inclined, 
and vrill not adhere even to the jelly. 



234 PROXIMATE ELEMENTS OF DISEASE. 

but if the obstruction increase a little by another white corpuscle or two 
more, so narrowing the path that the red particles can no longer pass, 
then these also stick, and, forced by the current from behind, their 
flexible and elastic bodies become jammed in such numbers in the inter- 
stices of the white corpuscles, that the whole vessel speedily presents 
an almost homogeneous deep red color, and contains a great accumula- 
tion of red particles, the liquor sanguinis having filtered through. This 
is the period of total obstruction, the process of which may be watched 
when the irritation is extremely gentle ; but in most instances it is pro- 
duced so suddenly and extensively that the successive changes escape 
observation, and the contents of the vessels at once appear stagnant 
and uniformly red, as if the blood had suddenly coagulated with them. 
These appearances are illustrated in the diagram (p. 262), and serve to 
explain the vascular redness of an inflamed part, and, as we shall see, 
will aid us in understanding the farther results of the inflammatory 
process. 

It seems, then, to be well established, that an essential part of inflam- 
mation is the production of numerous white globules in the inflamed 
vessels ; and that the obstruction of these vessels is mainly due to the 
adhesive properties of these globules. The production of these globules 
must then be considered as a constant fact in the history of inflammation 
and nutrition ; but it may be observed that sometimes it seems to be 
the direct efi'ect of an irritant acting on the bloodvessels and their con- 
tents (§ 415) ; in other instances, rather to result from determination of 
blood into previously congested capillaries (§ 414). Any circumstances 
causing continued determination of blood, where congestion is already 
present, will occasion the production of the white globules, and, conse- 
quently, inflammatory obstruction may ensue. The complete obstruc- 
tion of some capillaries by the confused conglomeration of the corpuscles 
takes place in all cases of severe inflammation of the frog's web ; but 
there are slighter kinds of increased vascularity, in which there is no 
total obstruction, but a continued enlargement of the capillaries and 
veins, as well as of the arteries. This might be called simple determi- 
nation of blood ; but it difi"ers from that of a transient character, in the 
motion in the capillaries and veins being slower, and in the vast number 
of white globules seen moving slowly in them (§ 294). Very probably 
this kind of process takes place in the lowest forms of inflammation. 
Something of the kind is generally seen in the capillary circulation of 
young frogs. 

419. The foregoing experiments and considerations lead to the con- 
clusion, that the most essential character of inflammation consists in an 
increased motion or determination of blood to the afi'ected part, with a 
more or less obstructed flow through the part; the force of the increased 
motion being partly expended in the arterial portion of the dilated 
capillaries (§ 414), and partly diverted into the collateral channels so 
abuudantly supplied by the anastomosis of vessels (§ 410). The obstruc- 
tion in the vessels of an inflamed part we have found reason to ascribe 
in part to the incr-eascd mass in the smaller vessels, and to the dimi- 
nished elasticity of their coats; and in part, to the unusual formation of 
white corpuscles, which adhere to the walls of the tubes, and to each 



INFLAMMATION — NATURE AND PHENOMENA. 235 

other. Of the exciting causes of inflammation, the direct irritants 
(§ 402) seem to produce obstructions in both these modes; those which 
act indirectly (§ 403), on the other hand, in the first instance produce 
congestion — to which determintion of blood being subsequently added, 
the inflammatory process begins ; hence the latter causes, although very 
common, are not so sure of exciting inflammation as direct irritants are. 

420. The eff'ect of these changes, essential to inflammation, is to ex- 
pend much of the circulating force conveyed by the arteries on their 
capillary terminations; and the enlargement and tortuosity of these 
capillaries, the production of globules which adhere to their sides, and 
their total obstruction by the same means, seem to be so many progres- 
sive expedients used by nature to direct the force of the circulation to 
that part of the vessels by which the process of reparation and nutrition 
is chiefly carried on. We have farther suggested, that an obvious efi'ect 
of this local direction or determination of force, is to supply oxygen more 
freely to the plasma, and the resulting formation of a solid deutoxide of 
proteine is the obvious explanation of the formation and increase of 
those white corpuscles which augment and complete the obstruction. 
This leads us to consider the farther changes efi'ected by inflamma- 
tion. 

421. We have already found that an inflamed part is the seat of 
determination and of congestion or obstruction. It is this combination 
which leads to the changes which characterize inflammation, and which, 
in extent and variety, exceed the changes from any other kind of 
hypersemia. The determination of blood to and near the obstructed 
vessels is attended with the usual results of determination (§ 333, &c.); 
but to a greater extent than usual, because the cause of determination 
is more permanent. The congestion or stagnation has also its eff"ects 
(§ 303, &c.) ; but more marked and peculiar than usual, because the ob- 
struction is more complete than in congestion in general, and because it 
is modified by the influence of a continued force of blood acting physi- 
cally and chemically against it. All these circumstances point out that 
the natural functions of the vessels must be much modified by inflamma- 
tion, and this in difi'erent modes in difi'erent parts of the inflamed site. 
Thus, in the vessels which are the channels of an increased flow, the func- 
tions will be more or less exalted or excited; whilst in those that are- 
obstructed, vital properties will be more or less impaired. It is the 
approximation of such opposite conditions, excitement and interruption 
of living actions almost in the same spot, that renders continued inflam- 
mation so seriously destructive to structure as well as to function. 

422. Inflammation at first much exalts sensibility (§ 133) and con- 
tractility (§ 111); causing tenderness, pain, and spasm. But the ob- 
structed circulation may cause a suspension of these properties (§ 273) 
in the centre of the mischief, whilst in surrounding parts, the seat of 
determination, they are exalted. The sympathetic relations (§§ 152, 156) 
of the inflamed part are also commonly increased. Natural secretions 
are either suspended by inflammation, or modified by the addition of 
various modifications of the serous and albuminous parts of the blood. 
This involves the change of nutritive- secretion, which is so important 
and early a part of inflammation that it must be noticed more fully. We 



236 PROXIMATE ELEMENTS OF DISEASE. 

shall recur to the other eifects of inflammation under the head of symp- 
toms. 

423. The effusions from inflamed vessels at an early period are much 
the same as those from tense congestion (§§ 305-8) and determination of 
blood (§§ 340, 1); but they commonly occur in greater abundance, con- 
tain more animal matter, and, as the inflammation advances, they some- 
times present appearances not found in the products of mere congestion 
or determination. Thus the effusion at first is a thin serum, causing 
swelling in complete textures, accumulating in the dependent parts of 
serous cavities, or diluting the secretion of the more simple mucous 
membranes. But soon fibrine is also effused, part of which may con- 
crete into coagulable lymph, or still remain dissolved, as in the liquor 
sanguinis. Thus an inflamed pleura becomes coated with a film of 
lymph ; and the clear fluid effused into the sac, when removed from the 
body, sometimes spontaneously separates into a fibrinous clot and serum. 
This occurring in complex textures gives a hardness to their swelling, 
as in phlegmon of cellular membrane, hepatization of the lung, &c. In 
mucous membranes, there may be thickening of the submucous texture, 
and the mucous secretion becomes unusually viscid. 

424. The microscope has supplied much detailed and precise informa- 
tion on the nature of inflammatory effusions, although there is yet room 
for farther research on their varieties and relations to each other. In 
the frog's web, after inflammation has continued some hours, there 
appear outside of the vessels (especially of those in which the strongest 
current encounters the most complete obstruction) white globules or 
corpuscles with specks in them, exactly like the pale granular globules 
within the vessels (§ 415). These are also found in various inflamma- 
tory effusions, and are called exudation corpuscles, granule cells, or 
fibrinous globules, Mandl supposes them to be merely consolidated 
globules of fibrine, and states that the liquor sanguinis may be seen to 
coagulate in similar globules on the glass of the microscope. But these 
latter have been shown by Gerber to be mere albuminous granules, with- 
out regularity of form, and quite unlike the true exudation corpuscle, 
which also consists of granules, but has a defined outline, and in many 
instances an investing cell, whence the term granule cell (Vogel). In 
addition to these bodies, the fibrine effused by an inflamed membrane 
also contains a mesh of extremely fine fibres, first noticed by Messrs. 
Gulliver^ and Addison.^ Both these observers describe the nucleated 
or granulated corpuscles as occurring among these fibres, together with 
more minute granules and molecules, which appear to be similar to 
those which compose the corpuscles. Lastly, some portions of solid 
effusion present no distinct structure, but are either irregularly granu- 
lar like coagulated albumen, or completely amorphous and homoge- 
neous (Vogel), hyaline (Gerber). Now, some or all of these solids 
appear in inflammatory effusions^ although they occur in very various 
proportions, and present different modifications, to be noticed hereafter. 
The following is a summary of these elementary solids of inflammatory 
effusions: — 

' Note to Gcrbor's General Aiintom}', p. 31. ^ Med. (Jaz. April 15, 1841. 



INFLAMMATION — NATUEE AND PHENOMENA. 237 

1. Molecules^ immeasurable from minuteness, each appearing as mere- 
ly a dark speck. Probably composed of a fatty matter (Davy, Gulli- 
ver). [Smaller primitive molecules; Gruby.) 

2. G-ranules (Gerber, Addison), measuring from yanoo ^^ ¥oVo ^^ 
an inch, appearing as a light spot, surrounded by a dark circle. Pro- 
bably consisting of deutoxide of proteine, with a central molecule of fat. 
(Larger primitive molecules, Gruby.) 

3. Fibrils, extremely fine, interlaced and decussating, the same with 
those seen in the buffy coat of the blood (§ 194). 

4. Lymph or exudation corpuscles, compound granules, granular 
cells, measuring from eo^oo *^ iho^^ ^^ i^^^ (Gulliver), composed of 
granules and molecules, and sometimes enveloped in a cell. 

5. Pus-glohules appear to be enlarged modifications of the last ; but 
more distinctly cells, containing liquid with more or fewer granules, 
some of which are of larger size than the rest, and forming nuclei. Be- 
sides the solid deutoxide of proteine, which constitutes these solid parts, 
they contain a dissolved form of proteine, the tritoxide. 

6. Irregular granular and hyaline matter; the former of albuminous 
composition, with more or less fat; the latter also albuminous, with more 
or less gelatine. These constitute the materials of tuberculous and 
other aplastic or cacoplastic deposits (§ 212). They often exhibit 
traces of cells and fibres, but appear degenerated or imperfectly formed. 

In addition to the above, inflammatory effusions usually contain the 
usual solids generated by the part, such as mucous globules, epithelium 
scales, epidermis, and also blood-corpuscles. 

425. Of these elementary solids, the fibrils certainly may form from 
the effused liquor sanguinis out of the vessels, and even removed from 
the body (Addison) ; but it is a question whether the others concrete 
spontaneously from the liquid fibrine, or grow from germs (molecules 
or granules) disseminated from the vessels or adjoining textures. The 
close resemblance of the exudation corpuscles and their contents, to the 
white globules and granules, so abundantly produced in the blood of the 
inflamed vessels, would seem to indicate their identity; but it is not easy 
to understand how they pass through the walls of the vessels, in which 
no pores are visible under the highest magnifying powers. Mr. Addi- 
son has, indeed, represented the white globules as first passing into the 
substance of the wall of the bloodvessel, and then beyond it; but this 
would seem too slow a process. It would appear more probable either 
that nuclei or molecules, too small to be discernible, do pass out in this 
way, and then grow and propagate compound granules (granular and 
pus corpuscles); or, that these corpuscles are formed by coagulation in 
the effused liquor sanguinis as the fibres of fibrine certainly are. 

426. These solid products of inflammation are the materials of which 
new membranes, textures, and deposits are formed; and present every 
variety of plasticity, or capacity of organization, from that of perfect 
cicatrices and false membranes, down to that of yellow tuberculous mat- 
ter.^ As we shall have to notice these farther, under the head of results 

' This statement, which is founded on the recent microscopic observations of Gerber, 
Gulliver, Addison, Watt, and others, is a remarkable confirmation of views on the nature 
of pus and tubercle, which I have entertained for the last twenty years, and to which I 
adverted in the following sentence, published nineteen years since : "I am myself disposed 



238 



PROXIMATE ELEMENTS OF DISEASE. 



of inflammation, we shall now review inflammation in relation to its far- 
ther consequences and symptoms. 

427. Inflammation is always attended with more or less efiusion. 
Where the inflammation is slight, this efi'usion may remove it by un- 
loading the engorged bloodvessels ; but where the inflammation is more 
intense, that is, where the obstruction is considerable, and the determi- 
nation of blood strong, the efi'usion may go on to a great extent without 
resolving the inflammation. It is then that the more serious efl'ects of 
inflammation result. The eifused matters press on, and pervade the 
adjoining textures, derange their nutrition, and impair their cohesion; 
and thus takes place the softe7iing o^ textures, which occurs chiefly in those 
of a complex kind, which retain the efi'used matter. The continued 
obstruction in the inflamed part, leaves the veins and lymphatics free 
to absorb, and the high pressure and determination of blood tend rather 
to promote this process of absorption. Hence, as new matters are 
efi'used, the old texture is compressed, disintegrated, and absorbed; the 
finer exudation corpuscles and fibres themselves are removed or altered, 
and the large pus-globules alone remain ; this is suppuration. Or, if 
the original obstruction of the inflamed vessels be extensive, or have 
been rendered so by the subsequent efi'usion, the supply of blood may 
be so stopped in a part that it dies, and the dead part may then either 
be only dissolved and absorbed at its circumference, and separated from 
the living textures in form of a slough ; or, if more extensive, the dead 
part may pass into decomposition before it can be separated; thus occur 
gangrene and sphacelus. If the inflammation be of a lower kind, the 
obstruction less complete, and the efi'usion more gradual, the nutrition 
of the natural texture is only impaired, not arrested, and from the in- 
creased deposition of solid matter, induration or consolidation takes 
place. 

SYMPTOMS AND EFFECTS OF INFLAMMATION. 

428. We have described the process of inflammation in its intimate 
nature and phenomena ; we have now to notice its more obvious efi'ects 
on function and structure, which become syr)iptoms of its existence. 
These symptoms may be divided into local and general; the local occur- 
ring chiefly in the part which is the seat of inflammation, the general 
aff'ecting the system at large. 



LOCAL SYMPTOMS. 



420. We have before stated that the local symptoms are commonly 
raorc marked, and earlier in order of occurrence when inflammation is 
excited by local irritation (§ 402) ; the fever which afterwards super- 
venes may even disguise the local symptoms. The chief local symp- 

to conf-idcr tubercular matter, pus, and coa,Grulal)lc lymph, only as varieties of the same 
albuminous matter that exists in the ))lood, and diflfering from each other rather in mecha- 
nical condition, and consequent capa])ility of organization, than in chemical composition," 
— Rational Expos, of J'lnjuical Siyna of Uic Diseases of the Luncjs and rteura, 1828, p. 159. 



INFLAMMATION — SYMPTOMS AND EFFECTS. 239 

toms have been already mentioned in the definition — redness^ heat, 
pain, and swelling, to which may be added various disturbances of the 
function of the part affected. We shall explain and illustrate these 
symptoms. 

430. The redness of an inflamed part is obviously due to the in- 
creased quantity of blood in the vessels. All these vessels are much 
enlarged, so that they receive many more red particles than usual; and 
the finest capillaries, which commonly are invisible from their admitting 
only the liquor sanguinis with now and then a red particle, are now 
distinctly colored from the number that pass into them. Some ob- 
servers have thought that new vessels are formed by the blood forcing 
its way through the textures. I have never seen this in the frog's web ; 
but it appears to take place in some textures which are not naturally 
vascular, such as the anterior part of the cornea, and cellular cartilage 
(Toynbee). But the microscope shows that, besides the augmented size 
•of the bloodvessels which convey blood, much of the redness of inflam- 
mation arises from the vessels in which the blood is stagnant. The 
color of these is much more red than that of the vessels simply con- 
gested, or through which a current still passes ; and this has before 
been referred to an accumulation of the red particles which takes place 
in them (§§ 415, 417, note). These vessels appear so impacted to their 
outmost limits with coloring matter, that the shape of the blood-disks 
and of the white corpuscles is no longer discernible ; yet these are still 
present ; for when an obstructed vessel reopens, the red mass breaks 
up into clots and particles, and many white corpuscles are left sticking 
to its walls. (See note, p. 237.) It is obvious, therefore, that the 
obstructed vessels become stuffed, as it were, with red as well as white 
corpuscles, which cause a brighter and stronger red than that of con- 
gestion. In many instances, too, it may be seen that the redness of an 
inflamed part is augmented by spots and patches of extravasated blood, 
which prevail especially in some varieties of inflammation. 

The redness of inflammation presents great varieties, according to the 
number and distribution of the capillary vessels of the part ; but its 
most essential seat being in the capillaries, its most constant character is 
a diffused or capilliform redness. This is commonly far more vivid and 
general in the living than in the dead body. In the skin and mucous 
membranes, during life, it is often seen as a uniform blush of color, vary- 
ing from a delicate pink to a bright crimson. After death, this blush 
has sometimes entirely disappeared; but commonly more or less of it 
remains ; and, on examination with a lens, it is found to consist chiefly 
of numerous vesicular striae, network, or points, with here and there 
larger vessels and ramifications also injected. But the large vessels 
(veins) are distended much less generally than in congestion (§ 280), 
and the redness is therefore less arborescent and ramiform. To explain 
the reason of the disappearance of inflammatory redness after death, 
we must bear in mind that much of it depends on determination of 
blood (§ 326) which is maintained by the action of the heart, distri- 
buted by the arteries ; and that when this ceases in death, the tonic con- 
traction of the arteries, which survives for a few hours, expels the blood 
from the vessels (§ 120). A similar effect is sometimes produced during 



240 PROXIMATE ELEMEXTS OF DISEASE. 

life, by cardiac syncope. The redness that remains after death seems 
chiefly to consist of the vessels which have become totally obstructed 
and impacted with blood, or have been long congested and have lost 
their tone (§ 295). This furnishes us with a useful means of distin- 
guishing in different cases the comparative prevalence of the elements 
of inflammation. Thus, in cases in which the redness disappears after 
death, we may know that the predominant element was local determi- 
nation of blood (§ 409), without much obstruction or permanent con- 
gestion. This is observed in erythematic and diffused membranous 
inflammations, the cutaneous inflammations of eruptive fevers, and the 
early stages of all inflammations excited by moderate local irritation 
(§§ 402, 415). On the other hand, if much redness remains after 
death, we may infer that obstruction or congestion of the vessels has 
existed to a great extent. This happens especially in phlegmonous in- 
flammations, those of parenchymata, and others which have advanced 
to a certain intensity, and those which have originated in congestion 

The florid hue of the redness is also, during life, a sign of the predomi- 
nance of determination, for it shows that the blood is chiefly arterial and 
not stagnant. Where congestion prevails, or where the blood has been 
long stagnant in many vessels, the' color is deeper ; but it is rarely so 
deep as in pure congestion, for the presence of white globules tends to 
lighten it or give it a florid tinge, and it is probable that the red par- 
ticles stagnant in the vessels retain their power of receiving oxygen from 
the communicating arteries, which are the channels of determination of 
blood. In the dead body, these distinctions are not equally available, 
for the arterial part of the blood may have been removed by the con- 
traction of the vessels, or darkened by stagnation ; and the livid por- 
tions speedily become florid on exposure to the air.^ 

The progress of inflammation modifies the redness. The color be- 
comes more florid and deeper as the inflammation advances to its acme ; 
it then becomes either livid before it subsides, or paler from the color of 
the effusion. In complex textures, the effused lymph or pus changes 
the redness to pink, flesh color, drab, or yellow. 

431. The heat of inflammation is obviously dependent on the increased 
flow of blood to and through the part ; and it may be considered the re- 
presentative of the amount of determination of blood concerned in the 
inflammation. Hence it is high in extensive and active inflammation, 
and is generally proportioned to the florid redness or arterial vascularity. 
It is not certain whether the high temperature of an inflamed part is 
caused by the augmented changes going on in that part, or whether it 
arises merely from the greater quantity of warm blood which passes 
through it. John Hunter made some observations to determine this 
point, and never found that the temperature of an inflamed part was 
raised above that of the interior of the body, which it might be expected 

' I liave often, in tlie (]ca<l-liousc, seen mere conpjestive redness mistaken for inflamma- 
tory, because it was flori<l from the action of the air, or from tlie translucence of a sub- 
jacent white structure. Frequently, too, the claret stain of arteries and intestines is 
mistaken for inflammatory redness ; a common lens will prove it to be not so, by showing 
that it is not vascular. 



INFLAMMATION — SYMPTOMS. 241 

to be, if inflammation was in itself a calorific process. That extensive 
inflammation raises the heat of the whole body, as well as of its own 
site, is quite certain ; but this may be simply by causing general excite- 
ment, especially of the circulation and respiration, and by repressing 
the perspiration and other exhalations, by which the body is naturally 
cooled. It seems, however, quite consistent with analogy to admit that 
inflammation, as a process of increased vascular action, may generate 
heat ; and inasmuch as there is an augmentation of the red particles in 
the part, which are supposed to be chief agents in the generation of 
heat (through the oxygen which they supply), we see a reason why the 
calorific process may be exalted in the inflamed part. Increased heat 
is a very important and valuable symptom of inflammation, since it is 
more constantly discernible than any other, and serves to distinguish in- 
flammation from congestion and nervous irritation, which may resemble 
it in other symptoms. But to indicate inflammation the heat must be 
continued, and not merely coming in flushes of simple determination of 
blood. Grenerally, the skin is dry as well as hot ; but it may be per- 
spiring, and yet a temperature, higher than natural, may be sustained. 

432. The sivelling of an inflamed part is caused, in some degree, by 
the enlargement of the vessels, but chiefly by the efi'usions from them, 
and will be, therefore, proportioned to the amount of these; but the 
situation, form, and degree of the swelling, will also greatly depend on 
the natural structure of the part inflamed. In serous membranes, the 
vessels being comparatively few, admit of but little enlargement ; and 
the efiusions, not being retained by complexity of structure, soon over- 
flow externally, and chiefly accumulate in the most dependent parts of 
the serous sac, causing dulness on percussion, and sometimes fluctua- 
tion in the chest and abdomen, and, when in large quantity, distending 
these cavities. Mucous membranes are more vascular and complex in 
structure ; hence the enlargement of vessels early causes some thicken- 
ing ; but the swelling is chiefly due to interstitial efl"usion in the submu- 
cous tissue (so manifest in coryza and cynanche) ; this effusion, when 
merely serous, soon passes off" in the thin flux which attends catarrhal 
inflammations, and the swelling may subside with it ; when the efl"usion 
is more solid, the swelling remains longer, is attended with a more vis- 
cid secretion, and subsides only when this secretion becomes opacjue, 
and somewhat fat in its composition. The skin presents great variety 
in the swelling, as well as in the redness caused by inflammation. 
Sometimes the swelling is diff'used and hard, as in cutaneous erysipelas. 
In urticaria, the same hard swelling occurs in spots or patches, and the 
eff'usion in parts supersedes the vascular redness, causing white centres, 
or wheals. In tubercular inflammations of the skin, the redness and 
swelling are still more circumscribed, and the eff'usion seems to be chiefly 
solid. In papulae, the swelling is even more minute, and confined to a 
point. In blebs and vesicles, the eff'usion is between the cuticle and the 
true skin, and the swelling is confined to corresponding patches or small 
spots. Inflammation of cellular texture is attended with considerable 
swelling; this being diff'used, oedematous, and pitting on pressure when 
the effusion is serous ; being more tense when there is fibrine with the 
serum; and being hard and subscribed (as in phlegmon) when the mat- 
16 






242 PROXIMATE ELEMENTS OF DISEASE. 

ter effused is cliiefly fibrine. Parenchymatous organs, in like mannery 
are remarkably swelled by inflammation. The liver, kidneys, testicles, 
lymphatic and other glands, attain a large size from the mere distension 
of their bloodvessels ; and we have noticed a similar result from mere 
congestion (§ 293) ; but inflammation does not last long in these struc- 
tures without causing eff"usion, which, by various proportions of serum 
and lymph, may cause swelling, varying in its firmness. The lungs, 
from their porous structure, do not swell materially in bulk; but the 
effusion displaces the air in their cells, thus increasing their weight, and 
if the effusion abound in lymph, converting them into a more or less 
solid mass, like liver (hepatization). 

433. The pai7i of inflammation is caused by that exaltation of sensi- 
bility (§ 135) which determination of blood produces (§ 333), often in- 
creased by the tension or pressure arising from the swelling. The 
amount of pain will, therefore, depend much on the natural sensibility 
of the part, the degree in which determination of blood predominates, 
and the tension or pressure induced. The severest pain arises where 
these circumstances co-operate, as in inflammation of the pulp of a 
tooth, the sheath of a nerve, the lining of a bony canal, as the auditory 
meatus, &c. In other cases, pain chiefly felt when the inflamed part 
is pressed or stretched, constituting excessive tenderness. Thus the 
pain of peritonitis is felt on pressing the abdomen, or on straining the 
walls by coughing or vomiting ; the stitch of pleurisy is felt on taking a 
full breath ; the pain of external inflammation and rheumatism, on mo- 
tion, or pressure on the limbs. In enteritis, there may be little pain 
until the intestines become spasmodically contracted in some parts, and 
distended in others, by flatus and other contents ; hence the pain may 
vary, whilst the inflammation remains the same. Parenchymatous or- 
gans and mucous membranes being comparatively soft and yielding in 
texture, are not the seat of much pain when inflamed. In the early 
stage, pain, with heat, may indicate the activity of inflammation, that is, 
the prevalence of determination of blood. In the more advanced stages, 
the pain rather bears relation to the amount of tension from swelling or 
effusion, and is commonly relieved when this becomes more diffused, or 
ends in suppuration. 

434. Besides pain and tenderness, sensibility increased by inflamma- 
tion sometimes exhibits other modifications, such as feelings of soreness, 
tingling, heat, itching, &c. Peculiar sensations are also excited in the 
organs of special sense when they are inflamed, such as noises in the 
ears, painful and disturbed vision, &c. The peculiar sensibility which 
excites the motions of sneezing, coughing, vomiting, micturition, and 
defecation, is exalted, when respectively the Schneiderian membrane, 
the lining of the upper part of the air-tube, the cardiac end of the sto- 
mach, the bladder, and the rectum are inflamed. Other sympathetic 
sensations (§ 150) excited by inflammation are peculiar to disease, as 
tlio pain in the shoulder-blade, with inflammation of the liver; pain in 
the testicle, with inlhunmation of the kidney ; pain of the glans penis, 
in inflammation of the bladder ; pain of the knee, with inflammation of 
the hip. 

435. Contractile fibre is not itself prone to inflammation ; when the 



INFLAMMATION — CONSTITUTIONAL SYMPTOMS. 243 

parts contiguous to it are inflamed, the effect is commonly first to increase 
its irritability (§ 113), and subsequently to impair it, probably by ex- 
haustion. Thus the heart, when its membranes are inflamed, acts first 
with great force and frequency, but subsequently with feebleness and 
irregularity. When the intestines, bladder, or air-tubes are inflamed, 
there is contraction followed afterwards by more or less weakness of the 
muscular fibres of these parts. 

436. Other functions are somewhat similarly affected under the influ- 
ence of inflammation. In inflammation of the brain and its membranes 
there is commonly at first more or less excitement of the sensorial func- 
tions, causing delirium, hallucinations, and convulsions ; afterwards en- 
sue stupor and coma, and paralysis. In the early stage of inflammation 
of the spinal cord, there may be tetanic convulsions ; afterwards follows 
paralysis. Often symptoms of partial excitement are conjoined with 
others of interruption of function ; and this is not extraordinary, seeing 
that inflammation comprises diminished as well as increased flow of blood, 
and the former generally predominates as the inflammation advances and 
effusion proceeds. Inflammation of the lungs causes dyspnoea ; that of 
the stomach interferes with digestion ; inflammation of the kidneys sus- 
pends or impairs their secreting power, &c. Farther details belong to 
special pathology. 

CONSTITUTIONAL SYMPTOMS OF INFLAMMATION. 

437. The irritation of inflammation frequently extends itself to the 
symptom at large. The functions of the whole body are more or less 
disordered. The contractions of the heart are more frequent and forci- 
ble than usual ; the arterial tonicity is increased (§ 121) ; hence the pulse 
is quick and hard ; the skin is dry and hot ; the appetite and strength are 
impaired ; and the natural secretions are diminished and otherwise dis- 
ordered. This is inflammatory fever. 

438. Among the most important general effects of inflammation must 
be noticed the change in the condition of the whole blood. We have 
before noticed, that there is an excess of fibrine and of the colorless glo- 
bules in the blood in inflammatory diseases (§ 195) ; and that the sepa- 
ration and contraction of this fibrine (§§ 203, 4) take place in an unusual 
degree, and produce the peculiar bufied and cupped appearance of the 
clot so remarkable in inflamed blood (§ 208). This excess and separa- 
tion of fibrine displayed in the huffy coat is commonly proportioned to the 
extent of the inflammation and its duration in an active state. This 
would suggest that the change in the blood is altogether produced in the 
bloodvessels in and near the inflamed part ; and the increased develop- 
ment of white globules, seen by aid of the microscope (§ 415) (which, 
chemically speaking, is an oxidation of some of the proteine), is a kind 
of demonstration of this production. This supposition derives support 
from the fact that blood drawn directly from an inflamed part is more 
buffed than that drawn from a distant part.^ This excess and separation 

_ ^ I have observed this even in blood dra-wn by cupping, on a part inflamed by the pre- 
vious application of a blister. 



244 PROXIMATE ELEMENTS OF DISEASE. 

of fibrine is more remarkable in inflammations of serous membranes than 
in those of mucous membranes, or parenchymata, which may perhaps 
be ascribed to the former inflammations being attended with less local 
vascular distension and overflow of the exudation corpuscles and fibrine. 
Acute rheumatism presents the highest degree of the buff" and cupping 
of the blood ; perhaps because the inflammatory irritation arising from 
matter in the blood itself (§ 251) affects a great many vessels, yet with- 
out completely obstructing them, so that determination of blood predo- 
minates over congestion ; and although there may be much inflammation 
and effusion of the early kind (§ 423), this does not lead to suppuration 
or other of the more destructive changes which follow inflammation. It 
has been before mentioned (§ 245), that an increased activity of circu- 
lation and respiration might contribute to augment the fibrine of the 
blood in acute rheumatism and other inflammations not impairing the re- 
spiratory function ; but it was then objected that the increase of the 
fibrine is sometimes observed in rheumatism without much acceleration 
of the pulse and breath ; and, on the other hand, in fevers in which the 
pulse and breath are much hurried, the fibrine of the blood is even di- 
minished (§ 196). And it w^as found by Andral and Gavarret, that, in 
fevers, the occurrence of local inflammation always caused an increase of 
the fibrine in the blood. 

It seems pretty clear, then, that the increase of fibrine, and its more 
contractile and separating quality, originate in the vessels of the inflamed 
part, and must be regarded as an augmentation of the process of nutri- 
tion developed by inflammation. A similar augmentation takes place 
in the vessels of the uterus during pregnancy, when the blood drawn 
generally exhibits a buff"ed appearance; and, although such an appearance 
is not commonly presented by blood drawn from fast- growing children 
during health, yet in them it is very readily induced by inflammation, 
and the plastic products are unusually copious. It has been mentioned 
(§ 415), that in young frogs, even in health, many white globules are 
seen in the bloodvessels adhering to or moving slowly along their sides ; 
and this appears to be a proof of the activity of the same nutrition or 
plastic process, which is exalted to its highest degree in acute inflam- 
mation. 

439. It has been supposed that the inflammatory or fibrinous state of 
the blood is the cause of the general excitement constituting the symp- 
tomatic fever accompanying inflammation ; but it may be objected that 
this fever frequently rises high before the blood has begun to exhibit 
the buffy coat, often subsides when the buffy coat is most abundant, and 
is sometimes wholly absent when the blood is both buffed and cupped, 
as in subacute rheumatism. It is very probable, however, that the ex- 
cess of fi])rine may contribute to the excitement ; and it certainly mate- 
rially affects the duration and products of the inflammation. 

440. In inquiring into the pathology of inflammatory fever, we must 
boar in mind that it sometimes precedes the distinct development of the 
local inflammation, being, in fjict, a general excitement or reaction after 
the disturl^ing influence of the exciting cause. This is especially the 

' T}i(; bufTod iippcarancc of the 1)loo'l in inflainmutory dropsy admits of a similar inter- 
pretation (^ySGj. 



INFLAMMATION — SYMPTOMATIC FEVER. 245 

case where inflammations are produced by cold, fatigue, and other causes 
which first induce congestion (§ 403). The operation of these causes 
is at first depressing to the whole system ; and the continuance of this 
marks the cold stage of the fever, with weak pulse, coldness of the ex- 
tremities and surface, general pallor, various uneasy feelings, dejection 
of spirits, and depression of strength. Afterwards ensues the reaction, 
beginning with rigors, accelerated pulse and breathing, sometimes vomit- 
ing, and other functional disturbances ; soon the skin becomes hot, the 
pulse hard, as well as frequent ; uneasy feelings in the head, back, and 
limbs are experienced, with thirst, loss of appetite, restlessness, and 
much weakness. It is during or after the establishment of this reaction 
that the local symptoms of inflammation may become prominent. Dur- 
ing the cold stage, they may have been chiefly those of congestion of 
the affected organ (§ 303), impaired function, with more or less uneasi- 
ness ; but now pain (§ 433), heat (§ 431), and various symptoms of local 
irritation (§ 434) ensue; and frequently, as these become developed, the 
general disturbance is somewhat reduced or modified. In eruptive 
fevers, the general disturbance and functional disorder are greatest be- 
fore the eruption (or local inflammation) appears. In inflammation from 
cold or fatigue, the first disorder sometimes resembles that of continued 
fever, which is changed for simple inflammatory fever as soon as the 
inflammation is pronounced. In other cases, again, chiefly those which 
originate from local irritation (§ 402), the inflammation is developed, 
and its symptoms are prominent, before the symptomatic fever is ex- 
cited. Generally, the fever is in proportion to the severity or active 
character of the inflammation ; and if it were always so, we might con- 
clude that the fever is the result of a reaction from the disturbance of 
the circulation produced by the inflammation ; but we sometimes find 
inflammation of trifling organs, such as the tonsils, attended with a very 
smart fever ; and much greater disturbances of the circulation, such as 
congestions of the lungs and liver, take place without causing any fever. 
It seems more probable, then, that the fever accompanying inflamma- 
tion arising from local irritation, is caused by an exciting influence pro- 
pagated from the inflamed part to the heart and arteries through the 
medium of the nerves. The same influence also sustains the inflamma- 
tory fever in the cases before noticed in this paragraph, in which the 
first febrile movement seems to be the result of reaction. 

441. It still remains unexplained why, in fever, the circulation and 
some functions are excited, whilst others, as secretion, muscular strength, 
and the appetites, are much impaired. We may partly solve this diffi- 
culty, if w^e may point out that the excitement is not one of a healthy 
kind, being attended with an excessive tonicity of the arteries (§ 121), 
which is the cause of hardness of the pulse, and which may transmit the 
blood through the capillaries too rapidly to permit of its proper changes 
by excretion. It is also possible that the vital powers of secretion 
(§ 158) maybe more directly impaired by the inflammation or its cause; 
for it is certain that, either as cause or effect, imperfect secretion is one 
of the most prominent elements of fever in general. Thus the bowels 
are generally costive ; the urine scanty and high colored ; the skin dry; 
the tongue clammy, with thirst; and ulcers or sores, that may have been 



246 PROXIMATE ELEMENTS OF DISEASE. 

discharging before, now become dried up. So, too, on the subsidence 
of the fever, all these secretions are restored. 

Finally, we may sum up the causes of the symptomatic fever of in- 
flammation under three heads : 1. Reaction after the depression, induced 
by some exciting causes, such as cold, fatigue, &c. 2. Irritation com- 
municated from the seat of inflammation, probably through the nerves ; 
most prominent in irritable constitutions. 3. The altered condition of 
the blood, comprising an excess of fibrine, and retention of excrementi- 
tious matter ; these especially sustain the fever. 

442. The fever accompanying inflammation is generally high — that 
is, attended with hard pulse, hot skin, and general excitement — -in the 
young, the sanguine (§ 38), and plethoric (§ 279) ; those, in short, in 
w^hom the vascular system is naturally active (§ 401). On the other 
hand, it is commonly low — that is, with weaker, though sharp and quick 
pulse, less general heat of skin, and with tongue more foul, and func- 
tions often rather oppressed or disordered than excited — in persons of 
phlegmatic temperament (§ 40), and in those weak from age, disease, mal- 
nutrition, in^temperance, or confinement. The type or character of the 
fever also varies with the seat of the inflammation, and the particular 
textures aff'ected, although the variation is less constant than it is gene- 
rally represented to be. It is commonly stated, that the fever is high 
in inflammations of most serous and fibrous textures, and in phlegmonous 
inflammation of cellular texture ; that it is low in inflammation of the 
stomach and intestines, kidneys, large joints, and in diffuse inflammation 
of cellular texture ; and that the fever is of an intermediate character in 
inflammation of mucous membranes and parenchymata. Clinical expe- 
rience, however, shows that there are many exceptions to these state- 
ments ; and where the type of the fever is aff'ected by the texture, it is 
chiefly by the intensity of the inflammation and the nature of its pro- 
duct. Diff"used inflammations, of little intensity, often excite very little 
fever, and few local symptoms. The reverse is the cause of very acute 
inflammations, even of moderate extent. 

443. The exciting cause, or some co-operating influence, often mate- 
rially aff'ects the type of the fever. The inflammation occurring after 
serious accidents or burns is often attended with a low fever, the reac- 
tion being imperfect from the continued depressing influence of the 
cause. The same remark is applicable to the case of inflammation from 
poisons, which are locally irritant, but sedative to the system. Even 
the long operation of cold may so depress the vital powers — especially 
that of the heart (§ 75) — that the reaction is imperfect, and the fever is 
low ; in all these cases the symptomatic fever is typhoid or adynamic 
(§ 25), with weak and unequal as well as frequent pulse, varying heat 
of skin, sometimes with partial sweats; a much furred, and often dry 
and brown tougue ; extreme depression of strength ; low delirium, and 
other nervous symptoms. These are indications of disordered state of 
the blood liko that induced by morbid poisons (§§ 186, 191) ; and it 
receives an adequate explanation in the want of purification and elimi- 
nation from which the blood suffers in its congested and imperfectly 
circulated state ; and the evidence of this change is afforded by the 
altered state of the blood-particles, the presence of urea, and signs of 



INFLAMMATION — RESULTS — RESOLUTION. 247 

incipient decomposition wliich have been observed in the blood in such 
cases, especially those of typhoid pneumonia (§ 25). 

444. In the lower forms of inflammation (§ 442), the fever may be 
remittent or even intermittent ; a state of depression alternating with a 
state of excitement, ending with perspiration ; and when inflammations 
become chronic, or are of slight character, they may excite no fever at 
all. They generally, however, induce some constitutional disorder, in 
which defective excretion (§ 171) is commonly a predominant element. 
When it is borne in mind that inflammation includes determination of 
blood, it will be obvious that, besides the irritation connected with it, 
there may be more or less exhaustion of other parts of the body (§ 331) ; 
the part inflamed being over-supplied with blood, other parts are in want. 
This eftect is most obvious in ansemic and debilitated subjects ; and to it 
must be ascribed the weak circulation, coldness, disordered functions, 
and gradual emaciation of the body in general, when a part long suffers 
from low inflammation. The blood itself also soon becomes impoverished 
in continued inflammation, losing progressively its proper amount of red 
particles, and the fibrine in protracted cases loses its organizable charac- 
ter and degenerates into cacoplastic or aplastic matter. 



NATURE AND SYMPTOMS OF THE TERMINATIONS OR RESULTS 
OF INFLAMMATION. 

445. The results or events of inflammation may be comprehended 
tinder four heads : Resolution^ Effusion (including adhesion), Sufimra- 
tion (including ulceration), and Gf-angrene. It must not be supposed 
that these often occur quite singly, or that they are so separated from 
each other by a very marked line ; but these terms are conveniently 
attached to those results in which each respectively predominates. 

Resolution consists in the cessation of the inflammation, and the speedy 
removal of any slight effusion. As the essential parts of inflammiation 
appear to be determination of blood, with obstruction to its flow through 
some vessels ; so the resolution of inflammation consists in the yielding 
of the obstruction and the subsidence of the determination, the vessels 
contracting to their normal dimensions. This may be well seen under 
the microscope. Sometimes nothing remains of the inflammation, but 
more or fewer of the white globules adhering to the sides of the vessels ; 
but more commonly some vessels are still obstructed, and others con- 
gested, with the motion in them slower than usual, the determination of 
blood (enlargement of the arteries) having ceased. So, commonly, we 
find congestion remain in a part that has been inflamed ; and not unfre- 
quently a flux or watery effusion may result from that congestion (§ 375). 

446. Resolution of inflammation may occur spontaneously in slight 
cases ; or in consequence of treatment ; or from the inflammation being 
transferred to another part. Someinflammations creep to adjoining parts, 
as in the case of erysipelas and some serpiginous cutaneous eruptions. 
Others affect similar textures in different parts of the body ; and, being 
resolved in one part, appear in another ; this happens in rheumatism, 



248 PROXIMATE ELEMENTS OF DISEASE. 

which affects fibrous textures, and is transferred from limb to limb, or 
joint to joint, by what is called metastasis, or translation. This maybe 
fairly traced to the mobility of the peculiar materies morhi (§ 402), the 
cause of the inflammation. A remarkable metastasis of resolving inflam- 
mation is sometimes seen in parotitis, the breast or the testicle becoming 
the seat, of the new attack. 

447. The occurrence of resolution is marked by a subsidence of the 
chief symptoms of inflammation ; first, of the heat and pain, and, more 
gradually, of the redness and swelling. The heat usually yields to per- 
spiration. The pain becomes gradually easier ; and in some parts, as the 
skin, may pass into itching before it subsides. The redness sometimes 
simply fades ; more commonly it becomes less florid, and may pass 
through shades of a livid or dusky hue before it vanishes. The swelling 
soon subsides ; the eff'used fluids being so speedily removed by absorption, 
that effusion can scarcely be said to have been a result. Still, in some 
instances, congestion, or some of its results (§§ 274, 350), or nervous 
irritation (§§ 126, 152), remains behind after the inflammation has 
ceased. 

448. The resolution of any considerable inflammation is marked by a 
reduction of the fever ; the pulse becoming softer and less frequent ; the 
skin moist with perspiration, sometimes profuse ; the urine, becoming 
more copious, abounding in urea, and depositing, as it cools, a plentiful 
lateritious or branny sediment, consisting of lithate of ammonia. The 
constancy of this last change on the decline of inflammatory fever has 
led to the supposition that it is critical, and determines the removal of 
the disease. The lateritious sediment in the urine is a pretty certain 
symptom of the subsidence of fever, and of the amelioration at least of 
the inflammation which excited it ; but it is uncertain how far it is the 
cause or the eff"ect of the improvement. It indicates an increased excre- 
tion of the solid constituents of the urine ; for there is often an. excess of 
urea as well as of the lithates ; and comparing this with the scanty se- 
cretion of urine during the febrile excitement and the decay of tissues 
and blood which is always taking place (§ 254), we can scarcely avoid 
the conclusion that these excrementitious matters had been accumulating 
in the blood from the impaired function of the kidneys during the fever; 
and that now, as the fever subsides, and their function is restored, the 
accumulated matter is thrown off. Now, although the function of the 
kidney must be first impaired to cause the accumulation of the excre- 
mentitious matter in the blood, yet this matter so retained tends to keep 
up the disorder (§§ 08, 171) ; and it is by means which promote the 
elimination of this matter that we succeed best in reducing febrile excite- 
ment. So, likewise, in cases where the function of the kidneys is per- 
manently impaired by Bright's disease (congestive degeneration, § 309), 
inflammatory ;uid other fevers are not readily brought to a termination; 
persons so affected arc said to be "bad subjects," Avith "broken down 
constitutions;" and they often sink because their excreting organs are 
unequal to tlie increased task thrown on them. In cases in which the 
resolution of the inflammation is only partial or imperfect, a daily 
remission or alleviation of the fever may take place ; and with it there 
is usually a deposit in the urine, of a pinker or lighter color than the 



INFLAMMATION — RESULTS — EFFUSION. 249 

usual brown lateritious sediment, and containing, besides lithate of am- 
monia, purpurate of ammonia and lithate of soda. 

Effusion {including adhesion). 

449. Effusion we have already found to be a result of inflammation 
(§ 423) ; but it is not always, like resolution, a termination of this pro- 
cess (§ 427). An abundant effusion of liquor sanguinis, of coagulable 
lymph and serum, of pus, or of inflammatory mucus, usually lowers the 
inflammation — that is, reduces the determination of blood, and may 
diminish the obstruction, but often does not remove it; and the effused 
matter may cause sundry mischievous effects, by compressing, stuffing, 
or obstructing the several structures in which it accumulates. We may 
with advantage pursue the history of effusions, by tracing their changes 
in the chief elementary tissues. 

Serous membranes^ being simple in structure, give us the best illustra- 
tion of the history of inflammatory effusion. In acute inflammation, in 
a healthy subject, besides serum, an exudation of fibrine or coagulable 
lymph takes place in a few hours. This fibrine is at first in a semifluid, 
ductile state ; so that the motion or pressure of the inflamed surfaces 
draws it into bands or threads, and exhibits the same adhesive properties 
which were before noticed, as belonging to one of its elements, the pale 
corpuscles within the vessels (§ 417) ; or spreads it into films, as we see 
it on the pleura, pericardium, and peritoneum. But if we examine in- 
flamed surfaces which are less exposed to motion or pressure, as the 
looser parts of the auricles of the heart, the serous covering of interlo- 
bar divisions of the lungs, that of the less projecting parts of the intes- 
tines, and of the convolutions of the brain, we find the deposit of lymph 
not uniform in a film, but in points forming a granular surface; which 
shows that either more is effused at some points than at others, or that 
the concretion of fibrine having begun in points, chiefly augments around 
the same points. The granules thus deposited vary in size, from that 
of a grain of sand to that of a millet-seed ; but if the deposit increases, 
they enlarge into patches, which may run into one another, often form- 
ing a mammilated coating of lymph. Even on surfaces which are sub- 
ject to motion, the prevalence of the fibrinous effusion at points is shown 
by a villous or shaggy appearance of the lymph, from this, in its ductile 
state, being drawn into threads projecting from the points where it has 
first concreted ; this is sometimes well seen in the pericardium. In the 
pleura, these inequalities are more obliterated by the rubbing motion of 
respiration, or by the pressure of liquid effusion. 

450. The lymph thus effused is (like the buffy coat of inflamed blood) 
at first transparent ; afterwards it becomes yellowish, and more or less 
opaque, but in inflammation of a healthy subject generally retains some 
degree of translucency. In this respect, it contrasts with the product 
of inflammation in unhealthy subjects, purulent and tuberculous lymph, 
which is more opaque. But the most important character of healthy 
lymph is its high susceptibility of organization, which character I will 
in future designate by the term eujjlastic (§ 211). Euplastic lymph con- 
sists of fibrils of fibrine crossing each other in various ways, and mixed 



250 PROXIMATE ELEMENTS OF DISEASE. 

with numerous exudation corpuscles, both compound (cells with nuclei 
•and granules) and simple (granules and molecules). Now, these are 
also found in the bufFy coat of inflamed blood (§ 212) ; and there can, 
therefore, be no doubt of their identity, and that the blood thus altered 
by the inflammatory process is their source (§ 438). This leads us to 
anticipate what is the fact, that the plasticity of lymph will depend much 
on the good quality of the blood, as well as on the energy of the inflam- 
mation. Healthy blood, which abounds in red particles as well as in 
fibrine, furnishes the most plastic kind of lymph (§ 183) ; and inflamma- 
tion, attended with the most active determination of blood (so long as 
the integrity of the vessels is preserved), separates this lymph in the 
greatest abundance. This lymph already possesses living properties, 
for its materials arrange themselves into the basis of a texture ; but to 
sustain the life of this texture, it must be supplied with blood, and this 
takes place in the wonderful process of the formation of bloodvessels in 
it, which communicate with those of the adjoining parts. 

451. The precise manner in which vessels are formed in lymph is still 
a matter of some obscurity. Mr. Kiernan observed inflamed capillaries 
become varicose, and at points project in pouches and diverticula, and 
stretch into loops. If these give way, the blood would be injected into 
the lymph ; and if something of channels were previously formed by the 
arrangement of the fibrils, or the elongation and communication of cells, 
it is quite conceivable that a current would be afi'ected by the vis a tergo 
through several openings, and that a return of the blood would take 
place by a reversal of the weaker currents. Mr. Travers has observed 
a process somewhat resembling this take place ; solitary red particles 
making their way into a bed of lymph-globules, and after for some time 
exhibiting an oscillating movement, give way to a current. The oscil- 
latory movement most probably depends on the pulses of the heart, as 
in the case of those described to occur in obstructed vessels (§ 418). 
Yogel describes the formation of new vessels, and even of the blood 
within them, as productions of the blastema, independently of adjoin- 
ing vessels ; but were this observation exact, we might expect frequently 
to meet with the appearance of vessels with blood in detached masses 
of lymph, and throughout the thickness of large clots accumulating on 
serous membranes. It has been ascertained by Schroeder, Liston, and 
others, that the new vascular channels are at first much larger than 
the vessels which supply them ; they are afterwards contracted by 
the formation of a basement-membrane lined with epithelium ; and the 
whole texture becomes more consistent and less bulky, exhibiting a fila- 
mentous and cellular structure, with nucleated cells scattered through 
it. These new membranes form patches on, or adhesions between, the 
serous coverings of the lungs, the heart, and intestines ; and provided 
these false membranes are loose, flexible, and of moderate thickness, 
that may cause no disorder. 

452. When the inflammation is of a low character, or when the blood 
is poor in red particles, and especially when these two conditions are 
combined, the solid products of inflammation are less capable of organ- 
ization, and therefore may be called cacoplastie. As the process of or- 
ganization varies in degree, so these products may attain to diff'erent 



INFLAMMATION — PLASTIC AND CACOPLASTIC. 251 

degrees of structure, forming membranes of a denser, less pliant texture, 
and less vascular than the serous membranes to which they are attached, 
and which thej therefore shackle. Thus patches of a kind of fibro-cel- 
lular or fibro-cartilaginous membrane are formed on the lungs, the heart, 
and the intestines ; sometimes with the effect of materially impeding the 
functions of these several organs. Where the effusion of lymph is scanty 
and slow, its granular mode of deposit is more obvious than in the more 
acute disease; for being less ductile, it is less readily spread or stretched 
by the motion of the parts (§ 449). This is well seen in chronic inflam- 
mations of the peritoneum and arachnoid, in which the deposit is almost 
entirely in granules or flattened patches, commonly called tubercles. 
These are generally of a buff or skin color, of firm consistence, and 
sometimes exhibit slight traces of bloodvessels in them ;^ but sometimes 
their color is more yellow and opaque, their texture uniform and tough, 
and they are totally destitute of vascularity. These constitute the form- 
ations described under the names cirrhosis and crude yellow tubercle, 
and are the lowest of the organized products. Being, in organization 
and consistency, dissimilar to the membranes on which they are formed, 
they prove a source of irritation and constriction; and being liable to 
ulterior changes (shrinking and contraction in the case of cirrhosis ; 
farther degeneration and softening in the case of yellow tubercle), they 
may bring farther mischief in contiguous parts. 

453. In some cases, again, more or less of the product of inflammation 
is aplastic^ or totally incapable of organization, and is thrown off with 
the liquid in separate large globules filled with granules and molecules, 
constituting pus ; or in detached opaque flakes or curds, consisting of 
aggregations of irregular granules, oil-globules, and molecules held to- 
gether by a few fragments of fibrils ; such effusions are exemplified in 
the sero-purulent liquid and curdy matter of low pleurisy, pericarditis^ 
and peritonitis. It is obvious that such lifeless products must act pre- 
judicially on the containing structures ; and the fact might be anticipated 
that they are little susceptible of absorption. 

454. I have mentioned (§ 452) a low form of inflammation, and an 
unhealthy condition of the blood, as causing the cacoplastic character of 
the products of inflammation. It may be added, that the long con- 
tinuance of any inflammation, and its occurrence in subjects in whose 
blood fibrine abounds, while the red particles are scanty (§§ 185, 195), 
will pretty surely render the products cacoplastic or aplastic. At the 
onset of inflammation, its products may be plastic, and the process of 
vascular organization (§ 451) may commence ; but if the inflammation 
continues, its product either is thrown beyond the reach of vascular 
communication, or displaces that already effused, and thus the outer 
layer will be in a degenerating condition. Added to this, the pressure 

' Mr. Dalrymple lias observed, that the vascularity of lymph may be seen earlier in 
cachectic and scorbutic subjects than in healthy lymph. But sj^philis and scurvy may mo- 
derate inflammation, without rendering the lymph aplastic ; the great impediments to or- 
ganization of lymph are, its bad quality and excessive quantity, and the persistence of 
inflammation. In a scorbutic subject, Mr. D. has shown that even a large coagulum of 
blood may soon become vascular ; but it does not follow that either this or lymph in such 
subjects can be formed into real texture. 



252 PROXIMATE ELEMENTS OF DISEASE. 

of the liquid effusion may impede the construction and injection of the 
new membrane, which therefore is degraded into one of the cacoplastic or 
aplastic matters above described. Again, in scrofulous or cachectic 
subjects the blood, although scanty in red particles, abounds in fibrine, 
and this is readily effused in inflammation ; but it is of low vitality, and 
susceptible of little or no organization.^ There is yet another circum- 
stance tending to lower the plasticity of lymph, although, according to 
the observation of Mr. Dalrymple, it sometimes accelerates its organi- 
zation^ — that is, the admixture of the coloring matter of the blood 
with it. Loennec supposed that contraction of the chest had its origin 
in hemorrhagic pleurisy only. This is not correct ; but I have many 
times remarked after death, that lymph on the pleura and pericardium, 
in cachectic subjects, is much stained with blood ; and where patients 
with similar symptoms have recovered from inflammation, they have 
been affected with structural disease. So far as we yet know, the co- 
loring matter does not form a material for organization ; and farther, it 
is very probable that in such cases the coloring matter is itself diseased 
(§ 186). 

455. The more complex structure and secreting properties of mucous 
membranes considerabl}^ modify the form and appearance of the products 
of their inflammation. But, according to Gerber, Henle, and Gruby, 
they microscopically consist of pus and mucous globules, granular cells, 
granules, and molecules, together with more or less amorphous and glu- 
tinous mucus and scales of epithelium. I must add, however, that in 
the early stage serum is present, manifest by the saline taste and coagu- 
lability by heat ; and at an advanced stage, the mucus acquires an in- 
crease of fatty matter. 

Irritation of mucous membranes merely causes a flux (§ 379), that is, 
the natural mucous secretion ; more copious, watery, and saline than 
usual, and containing fewer globules. But if the irritation be continued, 
and inflammation follows, the secretion is at first diminished by the 
effusion of serum and pale corpuscles into the interstices of the mucous 
and submucous texture, which causes more or less thickening or swelling. 
Soon, however, the effusion overflows to the surface, in the form of a 
more or less viscid, saline-tasted liquid, containing more globules and 
epithelium scales;^ and as the inflammation becomes more intense, the 
globules predominate, and the mucus becomes more scanty, but it is 
still very viscid. On the first decline of the inflammation, the mucous, 
and saline matters diminish, and the globules compose the chief mass of 
the secretion, and give it the yellowish or greenish opacity seen in " con- 
cocted" sputa; and this opaque matter is afterwards gradually replaced 

' Wlicn a coagulum of fibrine is retained long in a vessel Avitliout becoming organized, it 
loses its structure, and softens into an opaque semifluid matter, Avliich long was mistaken 
for pus; but Mr. Gulliver has shown that it consists of much smaller particles, mere ir- 
regular granules. In this state it bears the closest general and microscopical resemblance 
to mature and softened tuberculous matter. It appears to me, that certain softened tu- 
berculous appearances, met with in the lymph of serous membranes and parenchj^mata, 
are similar in their nature. 

2 Medico-Chirurg. Trans. 1810, p. 212. 

3 f!rul)y ; Mori)liology of the Pathological Fluids. Translated by Dr. Goodfellow (J/»- 
croscojjical Journal, Nos. VJ-To). 



INFLAMMATION — RESULTS — EFFUSI02T. 253 

by tlie natural mucous secretion. In many cases, especially in young 
subjects, and others in whom the inflammation penetrates to the sub- 
mucous cellular texture, fibrinous matter is thrown out, forming' films 
or shreds of lymph, or giving a fibrous or filamentous appearance to the 
mucus ; but this fibrine very rarely becomes organized on mucous mem- 
branes, because their secreting apparatus and its product lie between 
the lymph effused and the vascular structure. Hence the exudation 
corpuscles of inflammatory mucus are degenerating or aplastic, and con- 
stitute the opacity of viscid mucous, muco-purulent, and shreddy fibrin- 
ous matters exuded by inflamed mucous membrane. If inflammation 
persists in a mucous membrane, the globules continue to abound in the 
efiusion, commonly rendering it opaque and purulent; and the natural 
mucous secretion being impaired, the product is more difiiuent. But 
inflammation rarely continues long over a great extent of surface ; it is 
confined to patches, which yield their opaque efl"usion whilst other parts 
may be secreting natural mucus. Hence the compound appearance of 
the secretions in chronic inflammations of mucous membranes (bronchi- 
tis, mucous enteritis, and cystitis). 

Sometimes, interstitial efl"usion, which takes place at the comanence- 
ment of inflammation of mucous membrane, is not entirely removed by 
the subsequent dischp.rge. In such cases, there may remain a perma- 
nent thickening of the mucous and submucous texture, whichis the cause 
of the indurations and strictures which inflammation sometimes leaves 
in the intestines and urethra ; and, to a less degree, in the air-passages. 
This, however, it must be observed, is the result of inflammation, rather 
of the submucous cellular texture than of the mucous membrane itself. 

456. Inflammiation of the skin presents great varieties as to the 
amount and kind of its products. The full consideration of these would 
lead us into the pathology of skin diseases, a subject replete with inter- 
est and practical importance, although sadly neglected amidst the artifi- 
cial distinctions of writers on cutaneous diseases ; but the subject is too 
wide to be discussed here. 

Some of the eff"usions in and from the skin have been glanced atunder 
the head of the symptoms of inflammation (§ 432). It may now be added 
that these efi"usions may consist of clear serum, with few exudation 
corpuscles and molecules, as in the liquid of blisters and blebs, and ecze- 
ma, which dries into thin scabs ; or of milky serum, more abounding in 
the corpuscles, which dry into thicker scabs, as in herpes, rupia semplex, 
&c. ; or of liquor sanguinis and purulent serum, with more numerous 
corpuscles, which form very thick, yellow, or brown scabs, as in rupia 
prominens, impetigo, and ecthyma ; or the efiusions may be chiefly solid, 
and into the substance of the dermis, as in tubercula^r inflammations and 
incipient pustules. In all cases of inflammation of the skin, there is an 
increased production of epidermis, which is sometimes thrown ofi" in 
scales, with the scabs ; or in a peeling of the cuticle ; or thickens, and 
forms a hard covering, liable to clefts and sore ulcerations, as in psori- 
asis, inveterate eczema, &c. 

457. Inflammatory efiusion into the cellular texture consists of serum, 
with more or less of the exudation corpuscles and fibrine. In difi'use 
erysipelas, or cellulitis, the fibrine is deficient, and the corpuscles either 



254 PROXIMATE ELEMENTS OF DISEASE. 

are in moderate numbers, or else are degenerative (purulent). In phleg- 
monous inflammation there is more fibrine, which circumscribes the effu- 
sion, and causes a harder swelling ; and the pressure of this, with Sb 
continuance of inflammation, may lead to suppuration or sloughing. 

458. Effusions from inflammation of parencJiT/matous organs resemble 
those from inflammation of cellular texture ; but the parenchymata in 
general being very vascular, as well as yielding, the solid effusion may 
be very copious, without causing the pressure or tension that leads to 
suppuration and gangrene. The lymph effused exhibits, in regard to 
plasticity, the same varieties which we have described in the products 
of serous membranes (§ 450, et seq). But inasmuch as lymph effused 
in the parenchyma of an organ would greatly interfere with its function 
we rarely find it to become organized, except in limited portions, which 
thus remain solid and dense. More usually, the matter deposited is gra- 
dually removed by absorption or secretion after the inflammation declines; 
or, if the inflammation continues, the exudation globules and lymph are 
converted into, or replaced by, various kinds of pus or tuberculous mat- 
ter — consisting of degenerated corpuscles, granules, and fat-globules, 

459. Effusion so closely attends the process of inflammation, that the 
symptoms of effusion have been comprehended in those of inflammation. 
Swelling, pressure, obstruction, irritaltion, consolidation, displacement, 
and various functional as well as structural disorders, may arise from 
the presence of effused matter. Hence the occurrence of effusion may 
aggravate some of the symptoms of inflammation, whilst others may be 
more or less relieved by it. Where a copious effusion takes place, the 
pain, heat, redness, and fever are commonly reduced ; for the vascular 
and nervous excitement and determination of blood are lessened ; but 
the local or visceral disorder may be increased. The pulse may be as 
frequent, but it is less hard and full ; the fever less constant, but it .may 
continue in a lower degree, or assume a remittent or hectic form. The 
relief by effusion is greatest in slight inflammations, or where the effused 
matter can be thrown off from the body, as in the case of mucous mem- 
branes ; but there may be much irritation and exhaustion of strength in 
the process of throwing it off (as in cough and expectoration, diarrhoea, 
purulent micturition, &c.) ; and these will be more harassing where, as 
we have found is sometimes the case, the effusion does not remove the 
inflammation. 

Suppuration and Ulceration, 

460. The formation of pus among the products of inflammation has 
been several times noticed (§§ 424, 453, 455, 457, 458). Pus is an 
opaque greenish or yellowish white liquid, of creamy consistence, little 
odor, of specific gravity varying from 1080 to 1033. It is chemically 
composed of water, dcutoxide of protcine forming the cell-walls, tritox- 
ide of protcine and albumen in solution, fat, osmazome, and other ex- 
tractive matter, and the same salts as those in the blood. According 
to Gerbcr, mature pus contains more fat and less albumen than that 
recently formed. 

Microsco])ical]y, pus consists of a limpid scrum, and very numerous 



INFLAMMATION — RESULTS — SUPPURATION. 255 

globules of pretty regular size and form. These globules have much 
resemblance to granular cells or exudation corpuscles ; but they are 
larger and more distinctly and constantly provided with a cell-wall 
and nucleus, in addition to granules and molecules. Vogel describes 
their form to be in general spherical ; but sometimes irregularly rounded 
or oval ; their cell-wall is commonly opaque and somewhat uneven from 
being studded with minute granules. Acetic acid renders the walls 
transparent, and brings into view their nucleus, which, under the action 
of the acid, takes the form of from one to five somewhat elliptic disk- 
shaped bodies, clustered and attached to the interior of the cell. The 
existence of the cell, in most pus-globules, is also made clear by the 
action of distilled water, which causes the cell to dilate (by endosmosis) 
to double its former size ; and the larger granules or nuclei swell also, 
which shows their vesicular nature. Pus-globules are larger than the 
general size of exudation corpuscles (§ 424), and exceed in size the 
blood-disks (Gulliver). According to Mr. Addison, they measure from 
20^0 ^^ T3^o ^^ ^^ inch.^ Besides, in size, they commonly differ from 
other exudation corpuscles in being more distinctly vesicular, and con- 
taining a fluid as well as granules ; their more readily swelling, burst- 
ing, and shedding their contents under the influence of water or potass 
(Addison), may be referred to the same difference. In some instances, 
Vogel admits pus-globules to be devoid of a distinct cell-wall, as I have 
stated to be the case with some white or granular corpuscles ; and the 
only distinction of this kind of pus corpuscle, is in its exhibiting the 
peculiar trefoil or cordiform nucleus under the action of acetic acid. 

461. Another distinguishing character of the pus-globules is their 
want of cohesion ; and in proportion as they predominate, they impair 
the consistence of fibrine or mucus with which they may be combined. 
In this respect they contrast remarkably with the white corpuscles, which 
both within and without the bloodvessels we have noticed to manifest a 
remarkably adhesive and cohesive property. This and the other differ- 
ences may be explained on the supposition of the more gelatinous or 
semisolid parts of the white corpuscle becoming completely fluid, whilst 
the cyst becomes more solid and tougher than before ; such a change 
would account for the vesicular form and incohesive properties of the 
globules of pus ; and the extension of a similar change to the larger of 
the contained granules, would equally convert them into minute cells, 
which have the appearance of nuclei, with the usual endosmotic pro- 
perties. This liquefaction accompanying the formation of pus, is not 
confined to the contents of the pus-globule, nor even to the lymph 
and other products of inflammation ; it extends to the containing vessels 
and textures, which are softened, disintegrated, and removed, in propor- 
tion as the suppurative process proceeds. In complex textures, there- 
fore, whence the pus cannot escape, this process consists not merely in 
the formation of pus, but also in its substitution for more or less of the 
inflamed texture ; for this reason suppuration, more than effusion, may 

' Pus is not produced in birds, or in cold-blooded animals ; the reason of this is not 
understood, as the exudation corpuscles do not materially differ from those of mammalia. 
A careful investigation of the products of inflammation in birds as well as in quadi'upeds, 
would probably throw much light on the true nature of pus and lymph. 



256 PROXIMATE ELEMENTS OF DISEASE. 

be called a termination of inflammation, for the inflamed vessels are in 
great part destroyed. 

The chemical change which accompanies and probably causes this 
disintegration and liquefaction in the formation of pus, according to the 
researches of Mulder, seems to be an increased oxidation of the pro- 
teine, whereby it passes from the state of solid deutoxide to that of 
tritoxide, which is readily soluble in water or serum. But this farther 
oxidation and solution implies also a reduction of vitality in the exuded 
corpuscles, which thus lose their organizing power, and degenerate into 
a loose aplastic material. We shall find that the circumstances which 
promote suppuration, the nature of the process, and the symptoms 
which accompany it, exactly correspond with this view of the subject. 

462. The circumstances whioh determine suppuration as a result of 
inflammation, are chiefly three : 1. A certain intensity and duration of 
the inflammation ; 2. The excess of air to the part; 3. A peculiar 
condition of the blood. 

1. Intensity and continuance of inflammation comprise the persistence 
of the two chief elements of the process, determination of blood and 
obstruction (§ 419) ; and as we have found that the physico-chemical 
efi'ect of this is first to direct the force and exaggerate the influence of 
the red particles which convey oxygen, on the liquor sanguinis, so that 
more of its proteine passes into the state of solid deutoxide; a material 
fitted for organization and reparation ; — so we may infer that the exces- 
sive degree or continuance of the same process may overdo the change, 
give chemical properties an ascendency over the vital powers ; and by 
turning the most recently formed solid into a fluid tritoxide, it may efi'ect 
a work of separation and destruction which may involve the blood in the 
obstructed vessels, and extend to the albuminous matter of the contain- 
ing living texture. Such a result is more likely to ensue in complex 
and highly vascular structures, in which the efl'used matter is retained in 
intimate contact with the bloodvessels ; hence intensity and continu- 
ance of inflammation pretty surely lead to suppuration in the true skin, 
cellular textures, glands, and most parenchymatous organs. In serious 
and fibrous membranes, on the other hand, suppuration is a rarer result 
because the vessels are few, and the efl'used corpuscles less within their 
influence. In partial external inflammations, suppuration may often be 
prevented by pressure, which diminishes the determination of blood, and 
therefore reduces oxygenating influence. 

2. The access of air to a wound or to a serous membrane is well 
known to promote the formation of pus ; and it doubtless chiefly acts 
by directly supplying oxygen, and converting the fibrine and part of the 
exudation corpuscles into the soluble tritoxide of proteine ; but air may 
also operate as an irritant on a serous membrane or abraded surface, 
increasing the intensity of the Inflammation. A limited access of air to 
a large quantity of pus leads to a decomposition of the matter and the 
production of sulphuretted hydrogen, which acts as a deleterious poison 
on living structures. 

3. That a peculiar condition of the blood promotes the occurrence of 
suppuration after inflammation is obvious from tlie readiness with which 
all wounds, scratches, and pimples fester, and inflammations of no 



IXFLAMMATIOX — RESULTS — SUPPURATION. 257 

peculiar intensity and in various structures early lead to the formation 
of pus. This state of the system has been called the suppurative dia- 
thesis, and is presented in cachectic or ill-conditioned subjects, the quality 
of whose blood has been injured by malnutrition, imperfect excretion 
(§§ 171, 187), or by the direct operation of some morbid poison (§§ 258, 
296) such as that of erysipelas, confluent smallpox, glanders, &c. But 
the most efficient cause of the suppurative diathesis is the abundant pre- 
sence of pus itself in the blood (pyaemia), as in cases of phlebitis, dif- 
fused suppuration, &c. ; and it is most probable that this cause really 
exists in the examples above mentioned ; for Mr. Gulliver and others 
have detected pus-globules in the blood in many such cases ; and there 
is good ground to suppose that in all cases of suppuration some of the gra- 
nular corpuscles are converted into pus-globules vrithin as well as with- 
out the vessels ; but, for reasons that will afterwards be explained, this 
takes place only to a very limited extent under ordinary circumstances. 
The conversion of the white or exudation corpuscle into the pus-globule 
always implies a loss of vitality ; and therefore a peculiar proneness to 
the change (independently of intensity of inflammation and exposure to 
air) indicates a feeble state of the vital powers, which are unequal to 
resist chemical affinities. In extreme cases this tendency shows itself 
by the occurrence of gangrene, which often supervenes in the worst 
form of pyemia, as in malignant erysipelas and glanders. It is there- 
fore, quite intelligible that pus, either in a part, or in the blood at large, 
may act in the mode of a chemical ferment, promoting the formation of 
more, and tending to degrade the plasma of the blood from that organiz- 
able condition in which it can repair breaches or sustain the nourishment 
of the body. 

These considerations will throw much light on the farther process and 
symptoms of suppuration. 

463. The process of suppuration strongly illustrates the opposite cha- 
racter of the elements of inflammation before alluded to (§ 421). The 
obstruction to the passage of the blood through the capillary vessels of 
an inflamed part, and the increase of this obstruction by the pressure of 
matter efi"used by those vessels that are the seat of determination, reduce 
the vitality of the tissues to so low a degree, that they are unable to with- 
stand the chemical solvent power of the effused fluids,^ exalted as it is by 
high temperature. The textures are therefore gradually disintegrated, 
dissolved,^ and absorbed away, whilst the exudation corpuscles, swelling 
into pus-globules, occupy their place, and continue to be efl'used and de- 
veloped by the vessels which are still the seat of determination of blood. ^ 

1 That the liquid of pus can chemically dissolve dead animal matter was proved by J. 
Hunter, who found that pieces of raw meat were dissolved in abscesses, or even in pus 
kept warm out of the body. The experiments of Sir C. "VVintringham show that other 
animal fluids have a like property. Dr. Prout notices similar facts. This solvent property 
we have now reason to ascribe chiefly to the formation of the soluble tritoxide of proteine. 
A similar change takes place during the cooking of meat ; so that the old expression con- 
coted matter is not altogether metaphorical. 

2 The idea that the removal of textures in suppuration is owing to their death, origi- 
nated with Dr. Billing. (See his Principles of Medicine.) 

^ That absorption is increased in an inflamed part is farther proved by a direct observ- 
ation of Kaltenbriumer, who watched the gradual disappearance of the pigment spots in 

17 



258 PROXIMATE ELEMENTS OF DISEASE. 

This assumes that absorption is still active in an inflamed part ; and the 
assumption is warranted by the fact that the absorbing vessels, veins, 
and lacteals remain perfectly free ; and the very occurrence of increased 
pulsation and flow in communicating and contiguous vessels (§ 413), will 
promote the exosmosis of fluid matter by the absorbent vessels. That 
the pus- globules should remain unabsorbed will not appear extraordinary, 
when their large size is taken into account (§ 460), and that their cysts 
are not dissolved by their proper fluid, having acquired a remarkable 
degree of toughness. Their large size is wholly opposed to the notion 
that they are efi'used from the bloodvessels as pus-globules ; but their 
arising from the exudation corpuscles easily accounts for their appear- 
ance in the midst of lymph, and other products of inflammation, which 
they supersede as they enlarge and multiply. Thus the combination of 
apparently opposite results, which has been considered so inexplicable — 
excited and lowered action, increased secretion and increased absorp- 
tion — admits of an explanation in exact accordance with all the pheno- 
mena. 

464. The amount and extent of the process of suppuration varies in 
diS"erent cases. In cellular and parenchymatous textures, it sometimes 
occurs ^s purulent infiltration, not circumscribed by lymph, but leaving 
the texture much softened, and partially removed. This diffused kind 
of suppuration is to be referred, either to the porous nature of the organ 
(as with the lungs) not admitting an effusion of lymph sufficient to limit 
the suppuration, or to a purulent diathesis or disposition in the blood 
(§ 462). In most cases, the process of suppuration is limited around by 
solid eSusion, which may be either the remains of the earlier product 
of the inflammation, or it may be thrown out expressly for the purpose 
of defending the adjoining structure from the operation of the pus, which 
is obviously a noxious matter. A collection of pus thus circumscribed 
is called an abscess; and when mature, it represents the perfection of 
suppuration. The bloodvessels of the inflamed part are destroyed like 
other textures ; but their supplying trunks are obstructed by lymph ; 
whilst the adjoining capillaries, which remain pervious, become dilated 
and varicose on the wall of the abscess, which are lined with a coating 
of organized lymph, the vessels in which continue to secrete pus ; whence 
this lining is called jjyogenic membrane. As the pus increases, the ab- 
scess becomes enlarged, generally towards some cutaneous or mucous 
surface where it is said to -point ; the skin or membrane ulcerates, and 
the pus is discharged. The direction which the abscess takes, seems to 
be that in which there is least resistance ; the parts here are more stretched 
than others ; and from being stretched, their vessels are more obstructed, 
so that they cannot maintain the vitality, nor throw out the same amount 
of protecting lymph, which limits the extension of the abscess in other 
directions. Fibrous and other hard textures resist the progress of ab- 
scesses, and the escape of pus. Serous membranes, by their ready 
plastic process, first adhere together, and then often give passage to the 
contents of an abscess through them, without any pus escaping into their 

the frog's -web. This, however, was not suppui'ation, as that process does not occur in 
cold-blooded animals. 



INFLAMMATION — RESULTS — ABSCESS. 259 

sac. Thus, abscesses of the liver and kidney make their way across 
the peritoneum into the intestines, through the walls of the abdomen, 
and even through the diaphragm, pleura, and lungs. Where pus from 
an abscess does make its way into a serous sac, it causes severe irritation, 
and, commonly, fatal inflammation. 

465. After an abscess has opened, it may continue to discharge pus, 
pure, or diluted with serum or sanies ; but in healthy subjects, a process 
of healing takes place by an increased effusion of lymph, and growth of 
new vessels in it, in the form oi granulations^ throughout the interior of 
the abscess. Pus is still formed by the superficial layer of exudation cor- 
puscles degenerating or swelling ; and a free vent must be given to this 
pus, until the growth of the granulations, and the contraction of the 
walls, shall have obliterated the cavity of the abscess, and left no more 
room for the pus to accumulate. 

466. Ulcers sometimes arise from abscesses ; an abscess that has dis- 
charged its contents is, in fact, an ulcer. But more commonly, ulcers 
originate from limited inflammations of the skin or mucous membranes, 
in which the natural cohesion of the skin is so much impaired by the 
solvent action of the efl'usions on the tissue, that it is broken up at one 
or more spots, and either carried away in the pus discharged, or ab- 
sorbed. There is then left a solution of continuity or excavation, the 
bottom and edges of which continue to discharge pus, or a serous 
fluid, mixed with exudation corpuscles, and, sometimes, blood-particles. 
Ulcers may tend to spread by the same process ; or to heal by the eff'u- 
sion of fibrine on their walls, and the extension of vessels into this lymph 
in the form of granulations, which are the materials of the new texture. 
Ulcers, besides, present a great diversity of character in the nature of 
their secretion, and the condition of their walls, as well as in the symp- 
toms which they produce ; these circumstances constitute the varieties 
of ulcers described in surgical works. 

The cause of ulceration is commonly local, the inflammation suspend- 
ing the normal nutrition of a part, and promoting its solution (§ 460, 3). 
It is often preceded by induration from the amount of solid deposit; and 
the ulceration commences in the centre of the induration, because the 
nutrient influence of the vessels is most reduced by the pressure at that 
spot. But a very poor condition of the blood (hypinosis, § 196) is often 
much concerned in determining this result, and seems to be sometimes 
sufiicient to cause ulceration, without any distinct previous induration, 
or even inflammation ; the parts that sufi'er being either those which 
have become congested by posture (as in cachectic ulcerations of the 
Jegs), or those most remote from the nourishing influence of the blood ; 
such as the non-vascular textures, the cornea, cellular parts of carti- 
lages, &c. In cases of extreme anaemia (§ 268), where the fibrine and 
albumen of the blood are very defective (§ 197), ulcers of this descrip- 
tion arise, and are to be counteracted by measures the very opposite to 
antiphlogistic. A similar result was found, by Magendie, to ensue in 
animals fed on sugar, starch, and other non-azotized articles of food. 
In these instances, the ulceration and destruction of textures may be 
referred to prevalence of the solvent power exerted by the oxygen of 
the blood on materials whose vital power of resistance (§ 16) is much 



260 PROXIMATE ELEMENTS OF DISEASE. 

reduced, and for which there is no renovating supply in the plasma of 
the blood. 

467. Softening of textures roay arise from the same change which, 
in a greater degree, and more circumscribed space, causes ulceration. 
It has already been noticed as an effect of inflammation (§ 427) ; and it 
may now be added, that the condition of the blood which disposes to 
ulceration sometimes leads to the more diffused operation of the same 
change in the softening of textures. Thus softening of the brain, liver, 
muscle, and mucous membrane, sometimes results from anemia, or im- 
perfect supply of blood in these parts, or from spanoenia or impoverished 
condition of that blood (§ 197); and inflammation, which farther impairs 
or deranges the supply, may immediately determine the softening process. 

Local Symptoms of Suppuration. 

468. It maybe gathered from the previous description, that suppura- 
tion is a work of destruction, and therefore is, in some measure, to be 
contrasted with effusion of lymph, which is intended to be a process of 
construction or reparation. Pus is totally aplastic itself ; it is formed at 
the expense of the plastic product of the vessels, and the liquid of pus 
seems to act as a solvent or septic on textures when their vitality is re- 
duced. Although, therefore, suppuration is often useful in terminating 
inflammation, and in removing superfluous products and parts injured 
by it or its causes, yet suppuration must be viewed as a depressing and 
exhausting process, and its product as having a noxious character ; the 
symptoms which accompany it will be found to correspond with this 
view. 

469. The occurrence of suppuration is marked by a diminution of the 
heat, pain, and other signs of irritation and increased action in the part. 
The pain often becomes throbbing, as if the external pressure on some 
of the larger vessels had yielded, and these become expanded at each 
pulse. The swelling becomes softer; and if within the reach of touch, 
is felt to be first more yielding under the finger, and afterwards to pre- 
sent the fluctuation of fluid matter. The redness present in inflamma- 
tion is also diminished, being wholly superseded by the pale yellow of 
purulent effusion in the central parts of the suppurating mass, being 
mottled by it in others ; and retaining its deep character only in those 
parts of the circumference where the suppuration has not reached. In 
external inflammations, the redness of the skin becomes deeper before 
suppuration ; but when this process reaches the skin, a pale spot is seen, 
which, by its fluctuating feel, indicates the approach of the abscess to 
the surface. 

The great reason of the alleviation of the symptoms of inflammation, 
on tlic occurrence of suppuration, is the diminution of tension and hard 
swelling, which chiefly cause the pain and irritation (433) ; and where 
suppuration takes place amidst unyielding parts, as under a fascia or 
within a bone, the tension is increased rather than lessened, and the 
symptoms of pain and irritation may be more severe than ever. The 
powerful influence of hydraulic pressure in causing the injection of a 
liquid into a compact texture, and the swelling of the pus-globules by 



INFLAMMATION — RESULTS — SUPPURATION — SYMPTOMS. 261 

endosmosis after their first formation, will assist in explaining the eifu- 
sion of pus under a dense periosteum, or theca, and the extreme pain 
and irritation which it produces. The free secretion of pus from mucous 
membranes relieves inflammation, and removes the submucous deposit 
(§ 455). 

General Symptoms of Suppuration, 

470. The influence of suppuration on the system is manifest in the 
lowering of the inflammatory fever ; the pulse losing its strength, but 
retaining its frequency ; the heat subsiding, or alternating with chills and 
sweats ; the general redness being succeeded by paleness, or a hectic 
flush ; the urine depositing a pale or pinkish sediment ;^ and the general 
excitement giving place to weakness and exhaustion. The amount of 
the change will greatly depend on the extent of the suppuration, and 
the importance of the organ afi"ected ; but another chief circumstance 
determining the efi"ect of suppuration, and proving the noxious influ- 
ence of pus on the system, is the difi'erence between those suppurations 
that are diffused without a circumscribing barrier of lymph, and those 
that are thus limited, or are thrown off" at once from the body. 

In some cases of inflammation of the cellular texture, skin, and of 
serous membranes, pus is formed with little or no previous exudation of 
lymph, and produces in the system the most formidable effects. The 
pulse becomes very frequent and weak ; the tongue brown and dry, or 
coated with an off*ensive fur, and tremulous; sweats break out profusely; 
the urine is scanty, high-colored, and fetid, sometimes it is suppressed; 
a putrid diarrhoea occasionally occurs ; hiccough comes on ; the mind is 
much depressed, or excited by occasional delirium ; the patient's manner 
and motions are agitated and restless ; the breathing becomes hurried and 
sighing ; and death may ensue in from one to four days from the com- 
mencement of these symptoms. Similar results ensue in suppurative 
inflammation of veins ; and in injuries of the head ending in suppura- 
tion, communicating with some of the venous sinuses ; and they have 
been known to follow where an external abscess has suddenly subsided 
without opening, and in cases in which the discharge from a large sup- 
purating wound has suddenly ceased. On opening the body after death, 
in a few such cases, nothing peculiar has been found, except a general 
fluidity of the blood, and the gravitative congestions and stains which 
that fluidity induces (§ 196). In most instances, however, there are 
found in some of the viscera, particularly the lungs and liver, purulent 
deposits, as they are called ; collections of pus, generally confined to 
lobules or portions of lobes of these viscera, with more or less inflam- 
matory injection and deposition of lymph around the collections. In 
these cases there can be little doubt that pus in some way is conveyed 
in the circulation ; and being arrested in the lungs and liver, leads to the 
formation of more (§ 462) — whether by the production of suppurative 

^ The occurrence of urinary sediments after suppuration has been noticed by Schonlcin 
as a constant phenomena ; but such sediments are also observed after inflammation with- 
out suppm-ation, and must be regarded as the debris of plastic matter and textures icasted 
during the inflammatory process. 



262 PROXIMATE ELEMENTS OF DISEASE. 

phlebitis, as supposed by Cruveilhier, Dance, and others, is doubtful — 
and that the pus in the blood is the cause of the formidable symptoms 
and results above noticed. In several such cases purulent matter has 
been detected in the blood in considerable quantities, not only by the 
aid of the microscope, but by the pus-globules forming a visible layer 
on the surface of the red particles. From the experiments of M. 
D'Arcet,^ it is probable that the poisonous influence of purulent matter 
arises from chemical changes induced by air in its serosity (§ 460) ; but 
that obstruction to the circulation in the lungs and liver, and conse- 
quent circumscribed inflammations of these organs, result from aggre- 
gation of masses of the debris of the globules of pus contained in the 
blood. 

In those instances of the abundant presence of pus in the blood, it is 
not to be supposed that it is absorbed through the entire walls of blood- 
vessels ; the large size of the pus-globule, as before noticed (§ 463), for- 
bids that supposition ; but unusual channels of entry into the vessels 
have been in several cases discovered, as in the instance above men- 
tioned of an abscess in the skull opening into one of the sinuses ; to 
which may be added that in suppuration in bones generally, the pus may 
may find entrance through the open venous canals ; and in wounds of 
the neck it may be drawn in through the large divided veins under the 
suction influence of inspiration. Suppurative phlebitis has been already 
mentioned as an obvious cause of pysemia. Lastly, we must again ad- 
vert to the fact, first established by Mr. Gulliver, that pus-globules ap- 
pear in the blood in other cases of severe inflammation and suppuration 
where no opening into the veins is known to exist. In these instances, 
as before stated (§ 463), the pus-globules are probably formed within 
the vessels of the inflamed part ; and these increase and produce symp- 
toms of pyaemia only in cases in which the vitality of the blood is im- 
paired, and there is a proneness to the formation of pus from trivial 
causes (§ 462). To the latter group I would refer several instances of 
pycemia with the bad symptoms before mentioned, which I have seen 
after scarlatina, and in a few cases of acute albuminuria and typhoid 
rheumatic fever. Probably, too, malignant erysipelas and metroperi- 
tonitis belong to this class. 

471. The preceding observations prepare us for the fact that, besides 
the extreme eff'ects above noticed, extensive local suppurations cause 
various symptoms of depression or low irritation. Of this kind are the 
rigors often experienced at the commencement or increase of suppura- 
tion. Dr. Billing plausibly ascribes this to the system sympathizing at 
the death of the part which is under destruction by the supj^urating 
process ; but the rigor not being always present suggests rather that the 
presence of a certain amount of pus in the blood might be its cause ; 
and this may induce the shivering merely as a depressing agent, or very 
pi'obably by directly interrupting the calorific process by the withdrawal 
of a portion of the oxygen which sustains it (§ 461). This latter no- 
tion is countenanced by the remarkable and sudden fall of temperature 
Avliich often accompanies the extensive formation of pus. 

' •' ilcclierchcs sur Ics Absccs ]\Iulti]i]c9," &c. ; and Brit, and For. iMcd. Rev. Jan. 1843. 



INFLAMMATIOiS^ — RESULTS — GANGRENE. 263 

Again, wlien suppuration continues long, even if it be discharged out- 
wardly, as in extensive wounds, or ulcerations of the skin or mucous 
membranes, there is great wasting of strength and flesh, with a partial 
febrile irritation of a peculiar kind, called hectic fever. This is remit- 
tent in its symptoms, the exacerbations recurring once or twice daily, 
beginning with chills and depression, and followed by frequent pulse, 
partial heats, especially of the cheeks, hands, and feet, and ending in a 
profuse perspiration. As this proceeds, the body more or less rapidly 
wastes; and the colliquative sweats and diarrhoea, vomiting, and aphthae 
of the mouth, are so many proofs of the rapid decomposition and 
removal of the various structures, which tend to hasten the fatal result. 
The febrile part of hectic is most observed in the young and irritable ; 
but the depressing and exhausting effect of extensive suppuration is seen 
in all cases, in progressive emaciation and cachectic pallidity. 

472. The matter of abscesses is laudable or healthy in proportion as 
it is thick and opaque, but uniformly liquid and free from smell ; for 
although, even in this state, it is fit only to be expelled from the body, 
and is prone to decomposition, yet if excluded from the air it will remain 
unaltered for a long time. The formation of such pus is pretty sure to 
be attended with a protection of lymph, and it is far less noxious than 
ill-conditioned sanious matter, the fetor of which indicates that decom- 
position has already begun. 



GANGRENE. 

473. Gangrene, like the more complete forms of suppuration, may be 
well called a termination of inflammation, for the inflammation ends in 
the death of the part. In suppuration, the dying textures are softened 
and displaced by pus as fast as they die; in gangrene, the textures die 
more extensively than pus is formed, and they run into decomposition 
without being removed. In some cases, especially in limited gangrene, 
the dead portion is dissolved away at its circumference by the inflamma- 
tory exudation from the living parts, and it is thus separated or sloughed 
frotn them; but if the dead portion be extensive, and the power of the 
living parts low, the separating process will not be accomplished before 
decomposition ensues, which produces the changes called gangrene and 
sphacelus. 

474. The circumstances which cause inflammation to terminate in 
gangrene are those which completely suspend the circulation of the part 
(§ 273), and those which greatly injure the composition of the blood or 
directly destroy vital properties. The circulation in a part may be 
destroyed by long-continued pressure, by severe contusion, laceration, 
or other mechanical injury, by extreme heat or cold, by strong chemical 
agents, by the excessive pressure of the solid matter effused in the early 
stage of inflammation (as in carbuncle), and even by an extreme amount 
of congestion.^ The occurrence of gangrene is favored by extreme 

^ Two cases of gangrene of the lung whicli have occurred in my practice seemed refer- 
able to this cause. 



26-1 PROXIMATE ELEMENTS OF DISEASE. 

Tveakness of the heart, the great moving power of the circulation: and 
the failure is most manifest in parts most remote from the heart, as in 
various structural diseases of the organ, in low fevers, and states of 
extreme exhaustion. It is favored by ossification or partial obstructions 
of the supplying arteries, which, although adequate to maintain the 
ordinary nutrition of the part, cannot dilate to supply the demand in- 
creased by any injury or irritation of the part. The agents which 
cause^gangrene, by a directly destructive operation on the vital proper- 
ties of the solids and fluids of the body, are various strong poisons, such 
as arsenic, sulphuretted hydrogen, the poison of the rattlesnake and 
other venomous animals, the poison of the plague, malignant scarlatina, 
smallpox, and erysipelas, hospital gangrene, glanders, &c. 

475. An external part becoming gangrenous loses all feeling and 
other vital properties; its color becomes livid, or leaden, greenish, or 
almost black, the cuticle rises in blisters on it, and begins to exhale 
an offensive odor. The rapidity of this change will depend much on 
the moisture and warmth derived from the adjoining living parts; in 
dry gangrene^ the dead portion becoming horny and black instead of 
putrefying. For the converse reason, in internal parts the progress of 
decomposition is more rapid. The putrid matter afi"ects the living body 
(like many animal poisons) as a local irritant, and a general sedative or 
depressing agent ; and the symptoms will vary much as one or the 
other of these two operations predominates. 

In persons of robust constitution, active vascular system (§§ 112. 
120), and good blood (§ 195), a dead part arouses active inflammation 
and efi'usion of lymph in the surrounding living parts, which may pro- 
tect the system more or less completely from the infection of the dead 
matter. In such cases, although gangrene be present, the predominant 
symptoms may be those of inflammation and inflammatory fever. But 
living parts, with all their activity, cannot long withstand the pernicious 
influence of dead matter ; so that if this matter be not soon thrown ofi' 
in the form of a slough (§ 473), or liquefied in the inflammatory exuda- 
tions poured out, the system becomes infected, and sufi"ers from its 
poisoning and prostrating operation. This will happen more surely 
and early, where the dead part is in the interior of the body, of great 
extent, surrounded by vascular texture, and with its decomposition pro- 
moted by the warmth and moisture. In subjects of weak constitution, 
feeble vascular system, and blood defective in plastic matter (§ 196), 
the irritation of dead matter may fail to excite a protective (adhesive 
or plastic) inflammation, and the putrid or typhoid symptoms then 
show themselves earlier, and prove more speedily fatal. These symp- 
toms are — increasing feebleness and frequency of the pulse, reduction 
of tlic fever, collapse and extreme pallidity of the countenance, cold 
sweats, brown, dry, or clammy foul tongue, low delirium, or restlessness 
and agitation of manner, hiccougli, fetid diarrhoea, urine very ofl"ensive 
or suppressed, coma or syncope, and death. In external parts, or those 
which communicate with the surface, the putrid odor of the gangren- 
ous part becomes a distinguishing physical sign; in gangrene of the 
lungs it is communicated to the expectoration and breath ; in other 
cases, the whole body exhales a fetid odor. 



INFLAMMATION — STHENIC — ASTHENIC — ACUTE. 265 

The supervention of gangrene sometimes terminates the pain and 
other severe symptoms of the preceding inflammation, and this induces 
a false calm ; but they are often replaced by distressing symptoms of 
nervous irritation, which subside only with the collapse of death. 

i 
476. In concluding this account of the results or terminations of in- 
flammation, I must repeat what was said at the beginning (§ 445), that 
they rarely occur quite separately one from another, and in many in- 
stances they are all combined in difi'erent portions of an inflamed organ 
or texture. Thus, resolution is always attended with some amount of 
effiision ; lymph often has the color, opacity, and much of the micro- 
scopic character of pus ; suppuration is almost always preceded and 
generally accompanied by the efi"usion of some lymph ; and often ab- 
scesses are attended with gangrene and sloughing of parts ; and these 
combinations are farther illustrated by the terms, ^jurulent lymph, flaky 
jjus, sloughing ulcer, gangrenous abscess, &c., which pathologists are 
obliged to employ to describe what they meet with. 



VARIETIES OF INFLAMMATION. 

Inflammation may vary in consequence of the predominance or defect 
of some of its elements or results, or from its combination with some of 
the other elements of disease previously considered. Or inflammation 
may derive a peculiar character from the nature of its exciting cause, 
which is exemplified in what are called specific inflammations. The fol- 
lowing varieties demand a brief notice : sthenic and asthenic ; acute, 
subacute, and chronic ; congestive ; phlegmonous ; erysipelatous ; p)eUi- 
cular, or diphtheritic ; hemorrhagic ; and scrofulous. Of the specific 
inflammations, the gouty and rheumatic, syphilitic and gonorrhoeal, will 
be merely alluded to. 

477. The varieties of inflammation, termed sthenic and asthenic, cor- 
respond with the parallel varieties of plethora (§ 279), hemorrhage 
(§ 360), and flux (§ 393), and are referable to a difl"erence in the 
strength and irritability of the heart and arteries (§§. 110, 120, &c). 
Thus sthenic inflammation is marked by a strong hard pulse, high fever 
(§ 442), very fibrinous blood (§§ 208, 438), a full and active develop- 
ment of the chief symptoms or inflammation (§ 429), and a tendency 
generally to the more plastic products (§ 450). Patients aff'ected with 
sthenic inflammation require and bear a greater amount of antiphlo- 
gistic treatment ; and in them, if used in time, it is commonly most 
successful ; for sthenic inflammation occurs in those of the most robust 
constitution, in whom the efi"ects of disease are most readily shaken ofi". 

Asthenic inflammation occurs in persons, the tone and real strength 
of whose vascular system is low (§§ 116, 123), and their blood (generally 
speaking) poor (§ 207). The pulse is not always aff'ected; when it is 
aff'ected, it is in frequency, more than in strength or firmness; the fever, 
if there be any, is of a slight remittent, or low character (§ 442, &c.). 
The products are either scanty, or of a cacoplastic or aplastic character 



266 PROXIMATE ELEMENTS OF DISEASE. 

(§ 451) ; or the eiFusion may be chiefly watery, the inflammation differ- 
ing little from flux and dropsy. 

478. The terms acute^ sitbacute, and chronic, applied to inflamma- 
tion, properly relate to its duration ; but they are often used in the 
sense which I have given to sthenic and asthenic. Acute inflammation 
may be, and commonly is, sthenic ; but it is by no means always so ; 
its distinctive character is, that it tends to a speedy termination of some 
kind or other. It may end in resolution, effusion, suppuration, or gan- 
grene, in a period varying from a few days to three weeks. An inflam- 
mation lasting above the latter period is subacute, and if protracted 
beyond six weeks is properly called chronic. Yery commonly, inflam- 
mation is acute, because it is severe or sthenic, its intensity leading to 
a speedy result ; but asthenic inflammation is often also short in its 
duration ; whilst chronic inflammation sometimes presents a good deal 
of the sthenic character (§ 477). Acute inflammation, when at all 
extensive, is attended with considerable fever and constitutional dis- 
order. With subacute inflammation, the fever is less, and may even be 
absent. In chronic inflammation there is rarely fever ; when present, 
it is of a remittent or hectic kind (§§ 444, 471). 

The products of acute inflammation are commonly so copious as to 
be distinct in their character, being coagulable lymph, pus, inflammatory 
mucus, &c. In subacute inflammation they are often intermediate, such 
as purulent lymph, curdy matter, and tubercle in some of its forms. As 
with asthenic inflammation, the more they are in quantity, the less likely 
are they to become well organized. 

479. Chronic inflammation may originate in the acute or subacute 
forms, the vascular obstruction and excitement persisting in the part, 
even after some of the results (§ 445, formerly called terminations) of 
inflammation have been produced. Its general character is asthenic ; 
but there may be considerable determination of blood and local excite- 
ment. Its eff*ect in disturbing the functions, both of the part which is 
its seat, and- of other parts, is much less prominent than that of acute 
inflammation ; but its duration causes a more serious and lasting altera- 
tion of structure. The matter eff'used by serous membranes in chronic 
inflammation is always either cacoplastic or aplastic ; hence, dense and 
contractile adhesions, or patches of fibro-cellular or semicartilaginous 
matter, cirrhosis, gray miliary tubercle, curdy and yellow tuberculous 
matter, may be numbered among the common products of chronic inflam- 
mation. Mucous membranes discharge muco-purulent, or curdy matter, 
and the more complex membranes of this class become thickened and 
may ulcerate. Submucous textures become the seat of deposit, which, 
in becoming organized, often contracts, forming strictures in mucous 
passages. These strictures, by obstructing the passages, may lead to 
dilatations above them. In glands, and other complex textures, chronic 
inflainmiition causes consolidation and induration, which often afterwards 
contracts and effects the obliteration of the connected texture, as in the 
changes in the lungs, liver, and kidney, inaptly described under the 
name cirrhosis.^ Sometimes the indurated parts, from the pressure on 

' ^[r. Gulliver (Jcscribcs the consolidation of chronic pneumonia as characterized by 
"dark exudation corpuscles," as pale exudation corpuscles are the chief objects in red or 



INFLAMMATION — CHRONIC — CONGESTIVE. 267 

their vessels, become softened (§ 463), as in softening of the brain, or 
undergo a process of irregular suppuration and ulceration, as in the 
excavation of the lungs after chronic inflammation. As we noticed of 
congestion (§ 311), so it may be added of chronic inflammation, that the 
hypertrophy or excessive deposit of nutritive material is irregular, more 
in some textures than in others, generally abounding most in the inter- 
stitial cellular or filamentous tissue, which, by its hypertrophy, presses 
on the vessels and other textures, and often causes their atrophy and 
partial obliteration. Chronic inflammation in the cartilages ends in 
caries and ossification ; in the bones also, it causes caries or exostosis, 
just as in the skin and other compound textures it leans to induration 
as well as ulceration. The production of these apparently opposite 
results by the same process, inflammation, is not paradoxical, when we 
bear in mind the compound character of this process, and the variations 
arising from difi"erent proportions of its elements and products. Chronic 
inflammation exhibits these opposite results the more strikingly, because 
its eff"ectsare accumulated by its long duration; the hypertrophy arising 
from one of its elements (determination of blood) increases in the imme- 
diate neighborhood of atrophy and ulceration, the results of another of 
its elements (vascular obstruction). 

480. Congestive inflammation is that in which the accumulation and 
retardation of the blood in the vessels of the afi'ected part predominate 
over the determination of blood. Hence it is commonly asthenic in its 
character (§ 477), and generally originates from causes producing con- 
gestion in the first instance (§ 403), the reaction which converts this 
into inflammation being imperfect or partial. Its symptoms are less 
prominent than those of more active inflammation, and partake more of 
the character of those of congestion. Thus there may be little pain, 
heat, fever, and other signs of irritation or increased action; but the 
redness (where visible) is more marked and deeper than usual, and if 
the organ be very vascular (as the liver, lungs, and kidneys), the swell- 
ing may be considerable. Congestive inflammation is usually subacute 
or chronic, not tending to speedy results; but a kind of flux or dropsy 
may occur early, as from congestion (§ 375). So, too, the solid or 
nutritive efi"usion is generally cacoplastic, like that of congestion (§ 311); 
hence the consolidations or indurations arising from it are often of a 
dense indolent kind, tending to contract, or to degenerate still farther 
into aplastic matter (tubercle). The inflammation of the lung superven- 
ing on disease of the heart, on bronchitis, and asphyxia, is generally 
congestive ; and so is inflammation of the liver from any cause. 

481. Phlegmonous inflammation is exemplified in the phlegmon, fu- 
runcle, or boil of the integuments. Its chief character consists in its 
being abruptly circumscribed by an efiusion of solid lymph, which brings 
the inflammation to a termination, either by suppuration, or by slow 
subsidence, as in the case of blind boils. A highly fibrimous condition 

acute hepatization. It appears, however, that these corpuscles are not dark from color, 
but merely from opacity, as pus and tubercle are ; and they bear a farther resemblance to 
this last product, in their ii-regularity in shape, size, and composition, being of various shapes 
and consisting of molecules, generally without a micleus, and often without envelop. — 
Notes to Dr. Boyd's " Vital Statistics,'' Edin. Med. and Surg. Journ. July, 1843. 



268 PROXIMATE ELEMENTS OP DISEASE. 

of the blood (§ 195) contributes to render inflammation phlegmonous ; 
but this form of inflammation is that commonly exhibited by cellular 
and parenchymatous textures. The type of phlegmonous inflammation 
is usually sthenic (§ 477) ; and even where it advances to suppuration or 
sloughing, it defends the body against the noxious influence of the pus 
and dead matter. Hence the fever is more inflammatory (§ 442), and 
the local pain, irritation, and heat are considerable. 

482. Erythematic or erysipelatous inflammation is contrasted with 
phlegmonous, in its tendency to spread, not being attended with the 
efi*usion of plastic lymph. In its severe forms, it is accompanied by 
much redness, pain, or smarting, heat, and swelling ; the eflusion is 
chiefly serous or sero-purulent, and often raises the cuticle in blisters. 
In its worst kinds, it terminates in diff'used suppuration, sloughing, or 
gangrene. The fever is also of a lower type (§ 443) than in phlegmon- 
ous inflammation ; being attended by great weakness, disorder of the 
secretions, foulness or dryness of the tongue, with delirium, and con- 
fusion or dulness of the senses; and in the worst cases, the fever is 
typhoid, with stupor, muttering delirium, dry brown tongue, sordes on 
the teeth and lips, slight convulsive startings of the limbs (subsultus 
tendinum), fetid or suppressed excretions, and sinking. 

These adynamic or typhoid symptoms show the presence of something 
more than a form of inflammation, and that something must be considered 
to be a poison. It is probable that this poison sometimes originates in in- 
fection (§ 93) ; for persons in the same room, or who have had much com- 
munication with a patient with erysipelas, have been more frequently 
attacked than others; but it is also pretty certain that bad ventilation, and 
a crowded, uncleansed state of surgical patients, are capable at any time 
of rendering common inflammation erysipelatous ; and this efi"ect is much 
promoted by unknown epidemic conditions of the atmosphere (§ 89). The 
most probable hypothesis which we can form of this matter is that, under 
certain circumstances, the products of inflammation become (as we know 
they sometimes do, § 470) poisonous; and capable of acting (as many ani- 
mal poisons do) as local irritants and general sedatives or derpiments ; that 
they then modify the character of the inflammation, and depress the 
whole vital powers (as we have found pus and gangrenous matter do, 
§§ 471, 475); and that their eff'ects, and the general and local reaction 
against them (§ 17), lead to the various degrees and forms which we find 
erysipelatous inflammation and its accompanying fever present. The 
same morbid matter, being transferred by any of the three modes of in- 
fection (§ 94) to other persons, may induce erysipelas in previously 
existing inflammation, or if strong enough, may develop it anew in the 
body. The fact that patients often sicken with fever (rigors, vomiting, 
headache, quick pulse, delirium, &c.), before the erysipelatous inflamma- 
tion appears, is a sufficient proof that the poison acts on the constitution 
as well as on»a part; and the fact that weakly persons, and those with 
previous structural disease (especially of the kidneys), chiefly sufl'er 
from the worst effects of erysipelas, shows the essentially depressing 
operation of the poison. In several cases of the worst forms of erysipe- 
las, I have found pus-globules in considerable numbers in the blood of 
parts remote from the afl'ected textures; which corresponds with the 



INFLAMMATION — VARIETIES — PELLICULAR. 269 

observations of Mr. Gulliver (§ 462). This might suggest that pus is 
the poisonous matter; but although it is highly probable that these pus- 
globules do partake of the septic tendency formerly noticed as belong- 
ing to foul kinds of matter (§§ 462, 3), yet it is likely that the noxious 
matter occurs and spreads in a more subtle form, in solution or even 
in vapor, as shown by the pernicious properties of the liquor puris, and 
its fetid odor (§§ 470, 472).^ 

Some asthenic inflammations of mucous and serous membranes and 
internal organs exhibit many of the constitutional effects of the worst 
forms of erysipelas ; they sometimes prevail when it is epidemic, and may 
be traced to the same infection. This may be said especially of puerpe- 
ral metritis and peritonitis, erysipelatous tonsillitis and laryngitis, and 
suppurative phlebitis. 

483. Pellicular^ or diphtheritic inflammation of mucous membranes 
has some affinity to the erysipelatous, being diffused and spreading, gen- 
erally asthenic, and accompanied with a low kind of fever. It is at- 
tended with more soreness than pain, little swelling, and a deep redness, 
which is early obscured by the characteristic film of grayish or dirty 
white albuminous matter, which is exuded on the inflamed surface. 
Patches of this kind often occur on the tonsils in sore throat, and have 
been commonly mistaken for sloughs. In certain epidemics, often con- 
nected with scarlatina, a diphtheritic inflammation affects the whole 
throat, and sometimes extends to the trachea and air-tubes, the mouth, 
the gullet, and to more or less of the alimentary canal. The films of 
lymph thus effused are often fetid, apparently from incipient decompo- 
sition, which is promoted by their exposure to air and moisture in the 
throat and air-passages. As in the case of diffused suppuration and 
gangrene, this result of inflammation thus tending to putrefy is at once 
a sign of the low condition of the vital powers, and a cause of their 
farther depression. 

The exudation of lymph instead of mere mucus or purulent mucus, as 
usual, I am disposed to refer to the inflammation affecting the submucous 
cellular tissue, and being at the same time diffused like erysipelatous 
inflammation. Deep-seated inflammation of a more sthenic character 
is circumscribed by the effusion causing a thickening of the membrane, 
as in laryngitis ; but the matter effused by diphtheritis, although fibrinous, 
is thin enough to transude through the mucous membrane on the surface 
of which it concretes. The thinness of the mucous membrane of the 
air-passages in children facilitates the transudation in their deep-seated 
inflammations ; hence, at an early age, all such inflammations may cause 
an effusion of fibrinous matter, as we find exemplified in croup. So, 
too, the extreme tenuity of the mucous lining of the smaller divisions of 
the air-tubes makes the exudation of fibrinous matter a common result in 
pneumonia and some kinds of capillary bronchitis. This is exemplified 
in the ramiform moulds of the bronchial tubes sometimes expectorated. 
Similar skin-like exudations are sometimes passed from the intestines 
after the irritation of calomel or other strong purgative, and in some 
cases without any such irritation. I have had several patients under 
my care, who from time to time pass from the bowels a quantity of shreds 



270 PROXIMATE ELEMENTS OF DISEASE. 

like white kid leather, without any symptoms of active inflammation; 
congestion seems to be a chief cause in these cases (§ 308). 

In the mouth and throat, various asthenic inflammations seem to be 
capable of causing a fibrinous exudation, as that from mercurial action, 
and that in the aphthous mouth and throat of adults, which occurs to- 
wards the fatal termination of various chronic diseases. Recent micro- 
scopic observations have proved that in some of such cases at least, the 
film consists chiefly of a confervoid vegetable. I ascertained this to be 
the case with regard to a remarkably white curdy coating on the fauces 
and gums of an aged female now (July 1847) under my care in the hos- 
pital ; the matter was almost totally composed of the jointed tubes, and 
brilliant sporules and granules of the parasitic growth. The aphthae of 
children are somewhat difi"erent, being vesicular elevations of the epithe- 
lium, with or without an albuminous film underneath. 

484. Hemorrhagic inflammation is entitled to be considered as a dis- 
tinct variety. In most inflammations, there are slight extravasations of 
blood ; but sometimes there is so much coloring matter in the inflamed 
texture and in the products efi*used, that it may be difficult at first to say 
from the appearance whether the disease is a hemorrhage or an inflam- 
mation. These inflammations I have found to be asthenic ; often the 
subjects were scorbutic, or afiected with purpura ; and, as I have stated 
with regard to the latter disease (§ 358), there has been distinct evidence 
of imperfect action of the liver and kidneys. Thus, I have several times 
met with hemorrhagic pleurisy and pericarditis in conjunction with 
cirrhosis of the liver, and Bright's disease of the kidney. An altered 
condition of the coloring matter (§ 186) is perhaps more concerned in 
causing this result than a deficiency of the fibrine, to which it is commonly 
ascribed; in fact, this is found more or less in excess as in other inflam- 
mations, but very probably it may be defective in its usual contractile 
property (§ 203). 

485. Scrofulous inflammation is decidedly asthenic, and exhibits 
many deviations from the common form of inflammation. It may be 
well exemplified in the lymphatic glands, one of its most common seats, 
and within the reach of direct observation. These glands, in common 
inflammation, become very painful and hot, as well as swollen, and the 
inflammation tends soon either to resolution or to suppuration. In scro- 
fulous inflammation, on the other hand, lymphatic glands swell to a 
great size ; and often the deep redness extends to the surface, but with 
little pain or heat ; and the swelling remains for a very long period with- 
out either resolution or suppuration, and little influenced by antiphlo- 
gistic remedies. Sometimes it seems to suppurate, so that the swelling 
becomes distinctly fluctuating, and very red, as if ready to open ; but 
afterwards the skin becomes wrinkled, and the swelling subsides. When 
it docs burst, or is opened, the pus is serous and curdy, or mixed with 
matter of a soft cheesy consistence (soft tuberculous matter) ; and the 
abscess thus opened leaves a deep ulcer with a narrow orifice (fistula), 
which is indisposed to heal. The microscopic characters of scrofulous 
matter are a paucity and irregular form of the pus-globules and a great 
predominance of granular matter, loose or coherent in clots, and oil-glo- 
bules in considerable numbers. These characters at once explain both 



INFLAMMATION — VARIETIES— - SCROFULOUS. 271 

the aplastic and the indolent properties of the matter ; being destitute 
of the organizabilitj of fibrine, and of the cell-developing and endos- 
motic attributes of pus (§ 461). In proportion as it gets older, as in 
cold abscesses, the pus-globules become collapsed, and the liquid partly 
absorbed, the matter acquires a cheesy or putty-like consistence, and in 
time undergoes a farther change into fatty matter and phosphate of 
lime. The kind of inflammation from which this has originated occurs 
in persons of what is called the scrofulous diathesis, or constitution. 

The scrofulous diathesis is merely a term employed to designate a 
state of the body in which scrofulous inflammation and malnutrition 
are apt to occur. It has been generally stated that this diathesis has 
certain outward marks, by which its existence may be recognized, inde- 
pendently of the actual occurrence of disease. Thus, a relaxed state of 
the muscles, a soft transparent skin, a fair or pale complexion, with 
partial patches of a peculiar pink or purplish redness ; a pearly white- 
ness of the eye and teeth; tumid upper lip; fair or reddish hair ; large and 
weak joints, precocity of intellect, and some other signs, have been de- 
scribed as characteristic of the scrofulous diathesis. But such marks may 
occur without any manifestation of scrofulous disease ; and still more fre- 
quently, scrofulous disease is induced in persons quite destitute of these 
characters. 

More constant concomitants of the scrofulous disposition (although 
they sometimes occur without scrofula) are various signs of weak circu- 
lation and imperfect nutrition, such as cold extemities ; weak, but easily 
accelerated pulse ; small development of muscles ; uncertain digestion, 
and irregular excretion ; slow or defective healing of wounds. The 
circumstances which most favor the production of the scrofulous dia- 
thesis, are also causes of a weakening kind, especially when these are 
long continued, such as poor or insufficient nourishment, especially in 
childhood or youth ; cold and damp situations, or defective clothing ; 
long confiinement in close ill-ventilated habitations ; long-continued 
illness, especially from eruptive or typhoid fevers ; and prolonged and 
aggravated disorders of the digestive organs. Scrofula is also, in a 
marked degree, an hereditary affection (§ S6) ; and mere feebleness of 
constitution in parents, whether original or from disease, or from ex- 
cesses, or from age, often develops a disposition to scrofula in children. 

In persons of the diathesis now noticed, inflammation frequently runs 
a course, and leads to results different from those of inflammation in a 
healthy subject. Commonly, the inflammation is more asthenic (§ 477); 
often it is more subacute or chronic (§ 479) than usual ; but in all cases, 
its solid products are not euplastic (§ 450), as in healthy persons ; and 
may be either cacoplastic (§ 452) or aplastic (§ 453), according to the 
prevalence of the scrofulous constitution, the texture affected, and the 
quantity of the inflammatory product thrown out. Where the scrofulous 
diathesis is most developed — where the texture inflamed is an internal 
one, not freely discharging externally, and where the product of inflam- 
mation is most copious — there the deposit will be most aplastic, consist- 
ing of scrofulous pus or yellow tubercle, devoid of regular structure, 
and wholly insusceptible of organization ; and being not fit for absorp- 
tion, it operates as a foreign body, irritating, obstructing, and compress- 



212 PROXIMATE ELEMENTS OF DISEASE. 

ing the adjoining parts, in various ways detrimental to their functions 
and structure. Thus arise tuberculous or scrofulous deposits and ab- 
scesses in lymphatic glands, in bones, cartilages, and in the connected 
cellular textures, tuberculous infiltrations in the lungs, and deposits in 
serous cavities. Where the scrofulous diathesis is less pronounced, and 
the inflammatory effusion less copious and more gradual, the result 
may be a cacoplastic product, susceptible of only a low organization ; 
as gray, miliary, and tough yellow tubercle ; cirrhosis, atheroma of 
arteries, fibro-cartilage, and other degraded living solids. These have 
been already noticed (§§ 453, 454), and will again come under considera- 
tion as products of altered nutrition. The aplastic tendency of inflam- 
mation in scrofulous subjects is sometimes manifest in other forms in 
different textures. Synovial membranes of joints are softened into a 
brownish pulp {Brodie) ; articular cartilages and the cornea ulcerate, 
from absorption predominating over nutrition (§ 466) ; the integuments 
of the face and other parts inflame in small cutaneous tumors or tuber- 
cles, which ulcerate, and, for want of plastic material, the ulcers are 
phagedenic, spreading and destroying the nose or adjacent parts, as 
lupus. 

It seems, then, that the most constant peculiarity of scrofulous in- 
flammation is, that it degrades or arrests nutrition by supplying a mate- 
rial in a condition little or not at all susceptible of organization. This 
leads us to inquire what is the condition of the blood in scrofula ; and 
we are answered by the interesting fact ascertained by Andral and Ga- 
varret, before mentioned (§ 454), that there is an excess of fibrine (§ 195), 
but a deficiency of red particles (§ 185). The fibrine is, however, de- 
fective in that finely fibrillated structure indicative of vitality ; and this 
seems to favor the hypothesis that the red particles are concerned in 
preparing this plasma (§ 210) ; where they are" deficient, it is ill pre- 
pared. 

486. Gouty and rheumatic inflammations have already been noticed 
in relation to their specific cause, a morbid matter in the blood or in the 
textures (§§ 251, 254) ; and some of the peculiar characters of the inflam- 
mation were then adverted to (§ 385). It is highly probable that the 
peculiarities of many other inflammations, especially of the skin, such as 
urticaria, eczema, psoriasis, and erythema may be referred to a similar 
cause, a particular matter in the blood irritating the parts through which 
it circulates (§ 402). 

48T. The poisons of gonorrhoea and syphilis excite inflammations 
still more peculiar in their phenomena and course. Gonorrhoeal inflam- 
mation chiefly affects the genito-urinary passages and the conjunctiva. 
It is generally acute, and results in the secretion of an opaque sulphur- 
colored pus, which is capable of propagating the disease. Sometimes 
it affects the testicle also with acute inflammation, and the joints with 
more chronic, constituting gonorrhoeal rheumatism. 

Syphilitic infhammation exhibits great varieties in site and effects. 
Locally, the syphilitic poison may excite on any thin-skinned surface a 
papula, or small tubercle, which ulcerating, forms a chancre. As the 
matter is absorbed from this, it causes infiammation with great pain and 
swelling of the neighboring lymphatic glands (bubo), which may sup- 



CONSTITUENTS OF INFLAMMATION. 



273 



purate. These are primary inflammations, and of an acute character. 
When absorbed into the system, it may excite secondary inflammations ; 
sore throat, generally asthenic, and tending to ulcerate ; and a great 
variety of inflammations of the skin, which vary greatly in their type 
as well as in their character, according to the vigor, &c., of the subject. 
They often leave a peculiar lurid or copper-colored stain in the under 
layer of the epidermis, which obviously arises from an extravasation of 
some coloring matter of the blood, and probably implies a change in it. 
The periosteum and bones are also often attacked with syphilitic inflam- 
mation ; and painful nodes, exostoses, suppuration, and caries may 
result. The iris is sometimes attacked with acute inflammation and 
efiusion of lymph, which may endanger sight if not reduced. 



TREATMENT OF INFLAMMATION. 

488. We have found inflammation to be an essentially complicated 
process, composed of several constant elements, to which are frequently 
added others, which farther increase the complexity of the disease. A 
proper knowledge of these elements, and of the means which best re- 
move or counteract them, separately and in combination, will form the 
best guide to the rational treatment of inflammation, and will supply a 
safe clue through the confused and paradoxical assemblage of agents 
which experience has proved to be antiplilogistic remedies. As we have 
not time to discuss in full detail the elements and results of inflamma- 
tion with regard to treatment, it will be useful to enumerate these ele- 
ments and results, with references to the text, which more fully explains 
them, and then to represent in a tabular view the remedies that may be 
opposed to these elements and results respectively ; various combinations 
of which remedies constitute the antiphlogistic treatraent. 



489. Constituents of Inflammation. 



From operation r Congestion (|§ 403, 407), 



or 
exciting cause. 



Local elements 

of inflammation, 

(essential. ) 



1 

(^ Nervous and yascular irritation (|g 402, 408). 

Determination of blood towards the affected part (|| 409, 419). 

Obstruction of the vessels most affected (|^ 410, 419) ; by atonic en- 
largement of the capillaries (| 414) ; by production and adhesion 
of white corpuscles in the vessels (^ 415). 

Distension of arteries and capillaries before the obstruction (§ 420), 
causing increased effusion (| 423) of serum, lymph, pus, &c. (^ 427). 

Emptiness of veins beyond the obstruction (| 427), causing increased 
absorption (| 467), hence softening, &c. 

Impeded or arrested circulation at the obstruction (^ 418), causing a 
reduction or abolition of vital properties (| 273), hence the death of 
the part, and its removal by ulceration (^ 466) and suppuration 
(I 427), or its decomposition by gangrene (| 473). 

Increased circulation of blood arouxd the obstruction (^ 410), causing 
exaltation of vital properties (|| 421, 333); hence spasm (g 113), 
pain (§ 135), sympathetic irritations (^ 149), increased secretion 
{1 159), &c. 



18 



274 



PROXIMATE ELEMENTS OF DISEASE. 



Constitutional 

effects of 

inflammation, 

(not essential.) 



C Extension of the excitement to the heart and arteries (g 440), causing 
inflammatory fever. 

Change in the whole blood, by increase of fibrine from the inflamed 
part (§ 438), and by diminution of the excretions in the inflamma- 
tory fever (^ 441). 

Exhaustion ensuing aftdr the excessive excitement (§ 116), or the effu- 
sions of inflammation (|^ 459, 470). 

Depression, sometimes with partial irritation, from the presence of 
pus or gangrenous matter in the blood (§^ 470, 475) ; and retention 
of excrementitious matter (^ 443). 



490. TABULAR VIEW OF THE CHIEF ELEMENTS OF INFLAMMA- 
TORY DISEASE, AND THEIR REMEDIES. 



CONSTITUENTS OP INFLAMMATION. 

1. Congestion . . . , 

2. Irritation of nerves . 

3. — of vessels . 

4. Determination to the part . 

5. Obstruction in the part 

— by atonic enlargement 

6. — by adhesion of corpuscles 

7. Distension of vessels . 

8. Effusions .... 

9. Increased absorption . 

10. Impeded circulation in the part 

11. Increased circulation around 



ANTIPHLOGISTIC REMEDIES. 



J Astringents ; stimulants ; evacuants (| I g g 
\ 315, et seq.) ..... I '^'-^ 
Narcotics : counter-irritants (§^ 137, 155) |-'g g 
/ Sedatives ; derivatives ; evacuants (^ 342, | T § 
\ et seq.) ..... 






f Cold and other sedatives 
\ evacuants 



derivatives 



Remedies for congestion (see above) , 
J Remedies not known ; attenuants ? (§ 
\ 217); sedatives? (^ 416) 
J Counter-pressure ; bloodletting ; deri- 
t vation (^ 319) .... 

/Evacuants; derivatives; operations; sor- 
( befacients ?..... 

{Direct remedies not known ; stimulants ; 
diminishing atmospheric pressure on 
the part ..... 

Moist heat and other stimulants 
Remedies for determination (see above) J 

r General bloodletting and other evacu- ] 
\ ants ; sedatives (^115) 

{General bloodletting and other evacu- 
ants ; relaxants (antimony, &c., 1 122) ; 
salines ? . . . . • 

Change of the blood 

- by increase of fibrine . . | bloodletting and other evacuants (| 

•^ ( 214) ; mercury; low diet 

— by diminution of the excretions Evacuants ; alteratives (§ 172, et seq) 



12. Excitement of the heart 

13. 
14. 



o 



Exhaustion 
Depression from poison 



Stimulants and tonics 



[i^c 



antiseptics 



119, 124) . 
evacuants {{ 



18. Effused products of inflammation 



'I 

a 



( Stimulants 

I 260) 

f Evacuants ; attenuants ; alteratives ; sor- f S 
} befacients ? stimulants ; pressure, and | Z ^ 
( friction j "pS .S 

491. My limits will not enable me to do more than offer brief com- 
ments on these principles of the treatment, and to exemplify the above 
table by the results of experience; and it is an important corroboration 
of the truth of these principles that they expressly indicate the advan- 
tages of the various remedies which have been found effectual in the" 
treatment of inflammation, they suggest the peculiar uses of them re- 
spectively, and they open us a path of inquiry in pursuit of others 
which are yet wanting. 



INFLAMMATION — TREATMENT. 275 



Remedies for incipient Inflammation. 

1. Congestion. — The efficacy of topical astringents and stimulants in 
the congestion preceding inflammation, is illustrated in the effect of a 
strong solution of nitrate of sih^er or sulphate of zinc in curing conjunc- 
tival ophthalmia, and of the same agents, or powdered alum (Velpeau), 
or capsicum gargles, in curing an incipient sore throat. But as with 
regard to congestion (§ 317), so still more in the congestive stage of in- 
flammation, if it be extensive, long established, or already complicated 
with determination of blood, they can never restore the lost tone, nor 
clear the obstruction of the vessels ; and if not, they can operate only as 
irritants, and aggravate the inflammation ; and it is especially under 
these circumstances that evacuants, derivatives, and even bloodletting 
are more appropriate. The utility of these has been mentioned under 
the head of congestion (§ 318) ; but they may be more necessary in the 
congestive stage of inflammation, inasmuch as it tends to farther and 
worse results. A strong purgative and diaphoretic, if given early 
enough, may suffice to remove an incipient inflammation ; but if this 
inflammation be extensive, especially when the subject is plethoric, the 
proper remedy, even at this stage, is bloodletting, local or general, 
according to the situation and extent of the inflammation. 

492. — 2 and 3. Irritation of Nerves and Vessels. — The irritation of 
the nerves, which we have found to constitute a part of the commence- 
ment of some inflammations (§ 403), is so closely followed by irritation 
of the vessels, that their remedies are much the same. The efficacy of 
a large dose of opium in incipient inflammation exemplifies the utility 
of narcotics in subduing nervous irritation, and these remedies are the 
more indicated where pain, spasm, and other signs of excited nervous 
function (§ 151) predominate. On the other hand, where heat and red- 
ness rather prevail, the disturbance is more in the vessels, and the more 
appropriate remedies are sedatives, such as cold and saturnine lotions 
to the part, and various evacuants and derivatives, w^hich draw the blood 
away from the distended vessels. Counter-irritants or revulsives of the 
most speedy operation, such as heat, dry and moist mustard poultices, 
and other stimulating applications, near the affected part, seem to act 
both on the nerves and vessels, and are powerful means of subduing the 
irritation which leads to inflammation. In these applications, the effect 
on nervous irritation is proportioned to the sensation which they produce, 
and where pain or other sign of nervous excitement predominates, a heat 
almost scalding or burning, or stimulating agents which cause severe 
smarting, are most effectual. On the other hand, where the vessels are 
excited, as evinced by heat and redness (if visible), counter-irritants or 
revulsives which act extensively rather than intensely are of more avail; 
such as a general or partial hot-bath, or large poultice, or fomentation, 
made more stimulant by various additions.^ On the same principle, 

' A great improvement in the means of fomenting parts with heat and moisture, with 
or without stimulating additions, is supplied in various water-proof fabrics, such as India- 
rubber cloth, oiled silk, or gutta-percha sheet, being applied as a cover, to prevent the 
escape of the heat and moisture. I have for many years adopted these auxiliaries with 



276 PROXIMATE ELEMENTS OF DISEASE. 

purgatives and other evacuants continue to be indicated. Emollient 
and demulcent remedies, where they can be directly applied, often soothe 
an inflamed surface, both by promoting the natural secretion, by remov- 
ing irritating matter which may have caused the inflammation, and by 
reducing the acrimony of the morbid discharge, which is often acrid 
(§ 455). 

Remedies for established local Inflammation. 

493. — 4. Determination to tJie 'part. — This, with the following ele- 
ment, obstruction in the part, is only the farther result of irritation of 
the vessels ; but it is here named as a constituent of established inflam- 
mation. It is to be opposed by the same remedies as those just mentioned 
for vascular irritation, and formerly noticed as suitable for simple deter- 
mination of blood (§ 342, et seq.), but as part of a disease which is more 
enduring and serious, the determination attending inflammation requires 
a fuller than usual application of these remedies. Of the sedatives ap- 
plicable to this element, none is so effectual as cold, which we have 
found more than any other agent to promote the contraction of arteries 
(§ 120). It is thus that ice and cold lotions are very salutary in reduc- 
ing active inflammation, where they can be properly applied, as in ex- 
ternal inflammation ; in some internal inflammations the cold may be 
said to reach the interior, as by a bladder of ice to the head in menin- 
gitis, and by swallowing slowly small pieces of ice in gastritis. Cold 
will do harm instead of good in inflammation, either when it does not 
reach the enlarged arteries through which the determination takes place 
(§ 326), or when it is not sustained long enough to prevent the effects 
of reaction (§ 79), by which the arteries again become enlarged and 
determination is renewed. For these reasons, external cold applica- 
tions are injurious in most internal inflammations, and if not steadily 
regulated, they may prove so in other cases likewise. 

Warmth and other derivants, applied to parts more or less remote 
from the vessels which are the channels of determination, are very 
serviceable aids in the treatment of this element ; thus partial or general 
warm baths, hot poultices, &c., operate. Diaphoretics, which equalize 
the circulation without stimulating, such as antimony, are also bene- 
ficial, by relaxing the cutaneous vessels generally, and thus deriving to 
the whole surface. So we have found (§ 345) purgatives and diuretics 
to operate as derivatives as well as evacuants; and bloodletting was 
then stated to be the most effectual of all (§ 346). Change of posture, 
by elevating the part inflamed, should also be mentioned among the 
means which counteract determination of blood. 

These diff'erent measures, which may sufiice in simple determination, 
may be insuflicicnt for that attending inflammation, chiefly because they 
cannot easily be sustained for a length of time. To produce a more 
permanent derivation or revulsion, as well as to act as counter-irritants, 
various agents arc used to excite artificial inflammations, which counter- 
great advantage, especially where a prolonged effect is desired. The new ludia-rubber 
epithems, called piliue and spongio-piliue, recently introduced into this country by a for- 
mer pupil of mine, Mr. Markwick, answer the same purpose. 



INFLAMMATION — TREATMENT OF ITS CONSTITUENTS. 277 

act inflammatory disease by deriving and irritating in another direction. 
To this class belong blisters, mustard poultices, applications of tartar 
emetic, croton-oil, strong ammonia, mineral acids, some essential oils, 
heat above 120° Fahrenheit, &c. ; varying in the amount of inflammation 
which they excite according to the manner and duration of their applica- 
tion. As these fulfil several indications in inflammation they will again 
come under our notice. 

494. — 5 and 6. Obstruction in the pa7% hy atonic enlargement of the 
capillaries^ and hy adhesion of the white corj^uscles and accumulated im- 
paction of the red. — These are classed together, because they jointly 
continue to produce the partial obstruction which is characteristic, of 
inflammation. The atonic enlargement of the capillaries may be thought 
to be included in the congestion before noticed ; but it stands here as a 
part of established inflammation, and therein difi'erent from mere conges- 
tion (§ 287). The remedies to be opposed to it are, however, the same 
as those mentioned under that head ; but here they generally occupy a 
subordinate place, unless they fulfil other indications. There are, how- 
ever, a few cases in which the treatment for congestion, even by stimu- 
lants, proves efi"ectual in curing inflammation. Catarrhal inflammations 
of mucous membranes are sometimes removed by a highly stimulant 
treatment with wine, spirits, or ammonia. It is probable that the circu- 
lation is so much accelerated as to excite the dilated vessels to contract, 
and the obstruction is thus swept away. This treatment generally causes 
sweating and a deposit in the urine ; but these seem to be as much the 
efi"ects as the causes of the improvement, for sweating by other means is 
not so effectual. But this mode of treatment is hazardous, for it acts 
by increasing the flow of blood, and if this fail to remove the obstruc- 
tion, it will surely aggravate the inflammation. 

But the most constant and important part of the obstruction of in- 
flammation is due to the unusual formation and adhesion of the white 
corpuscles in the inflamed vessels, and the consequent accumulation of 
red particles entangled in them ; and inasmuch as it is this especially 
that establishes inflammation, and is the cause of its most serious results, 
it would be most desirable to find some remedial influence to counteract 
it. Unfortunately, however, we are not acquainted with any direct 
means of preventing the formation and cohesion of these pale globules, 
or of dissolving them when formed. As these globules appear to be 
formed in the blood-liquor, we should look for the desired remedies 
among the medicines which afi'ect the blood ; and it might be surmised 
that alkaline and other salts may possess this virtue. The efficacy of 
carbonate of potash as an antiphlogistic remedy has been much vaunted 
by Sarconi and other Italian writers ; but this is not confirmed by gen- 
eral experience. In fact, it appears from the experiments of Mr. Blake 
(§ 214), that salts of potass, injected into the "veins, promote the coagu- 
lation and stagnation of the blood instead of preventing them. Again, 
if the chemical view of their formation which we have proposed be 
correct (§ 417), it may be inferred that such means would be most ef- 
fectual as would interrupt the hyperoxidation of the plasma; and as 
this depends on the determination of arterial blood to the part, we are 
led to see a new and important advantage accruing from the operation 



278 



PROXIMATE ELEMENTS OF DISEASE. 



of depletion, derivation, sedatives, and other means calculated to reduce 
the force of the local and general circulation, and the richness of the 
blood which supplies the inflammatory material. Whether any deoxi- 
dizing agent could be made to assist towards the same end is a question 
worthy of investigation ; most materials of this description are object- 
ionable on account of their stimulant or heating influence, as, for exam- 
ple, alcohol and oils ; and in a minor degree, sugar and starch. The 
deoxidizing agent should possess no such property, either before or after 
its own oxidation. Has the antiphlogistic operation of antimony and 
mercury any relation to this mode of action ? Their virtue is chiefly 
confined to their protoxides and proto-salts. Analogous preparations 
of other oxidizable metals, which have no stimulant or injurious action, 
and sulphurets of metals and alkalies, have formerly enjoyed some repute 
as remedies in inflammation, and may deserve farther trials. The most 
efficacious remedy that I know for certain cutaneous inflammations, such 
as acne simplex in an excited state, is a weak solution of sulphuret of 
potash used as an outward application ; and sulphuretted waters are 
acknowledged to be useful soothing agents in irritable states of the ali- 
mentary canal — both possibly owing to an operation of this kind. 

495. — 7. Bisteiision of Vessels. — This is another of the more charac- 
teristic constituents of inflammation, and has been explained to be the 
result of determination of blood into congested and obstructed vessels. 
In congestion, we formerly found distension sometimes to occur (§ 306); 
but there it is chiefly in the veins ; here it is in the small arteries, and all 
those parts of the capillaries that are on the arterial side of the obstruc- 
tion. This may account for the greater degree of distension, and the 
larger amount of efl'usion and other changes that result from it. But 
the peculiarity of the inflammatory distension and of the ejQTusions which 
result from it, cannot be well understood, without keeping in view that 
concentration or exaggeration of influence exerted by the red particles on 
the liquor sanguinis, when, on their accumulated and impacted masses, 
a strong current of arterial blood is continually impelled (§ 416). This 
view, too, suggests that the most efi*ectual means of relieving it will be 
by speedily lessening either the determination of blood or the obstruction. 
The measures for reducingthe determination must be now of the strongest 
kind, such as bloodletting and free derivation or evacuation ; because 
the arteries wliich are the seat of determination are closed at most of 
their capillary ends, and must be drawn upon either directly or through 
means which reduce the pressure in the arteries generally. Where, 
therefore, there is any considerable determination of blood, the disten- 
sion which it causes will not be relieved without drawing blood either 
from the enlarged vessels themselves, or from other parts, in sufficient 
quantity to reduce the heart's action and the general arterial pressure. 
Other slighter moans g^ve some relief to the distension of the vessels 
ill inflammation. External pressure, carefully equalized, can sometimes 
do this, as in the effect of well-applied bandages and strapping on 
wounds. Fluid pressure, as proposed by Dr. Arnott, by means of quick- 
silver, or the slack air-cushion under a bandage, might be still more 
useful in various external inflammations, because its c(|uality insures its 
proper application. It is very probable that a part of the efficacy of 



INFLAMMATION — TREATMENT OF ITS CONSTITUENTS. 279 

poultices depends on the soft and uniform pressure which thej produce 
on the inflamed vessels. But certainly poultices, fomentations, and other 
means of applying moist heat, relieve distension in part also by relaxing 
the solid fibres, and by promoting the exudation of the watery parts of 
the blood. 

496. — 8. The effusions from the vessels are the result of their con- 
tinued impulsive distension. They may, therefore, be prevented or 
lessened by means which reduce this distension ; but in severe cases of 
inflammation, efi'usion is the natural mode in which the vessels are 
relieved of their load ; and we have just mentioned that poultices and 
fomentations give relief by promoting this result. If the effusion is 
outwards, as from a mucous membrane, it may not be necessary to 
check it, except so far as it may interfere with the functions of the part; 
but if it be too thick, alkaline medicines sometimes succeed in attenuat- 
ing it, and thus promote its discharge ; whilst acids and various astrin- 
gent remedies check it when it is too profuse ; but blisters and various 
evacuants should be combined with these last, otherwise the inflamma- 
tion may be increased. This corresponds with what has been said of 
the treatment of sthenic fluxes (§ 393). When the effusion is in cellular 
texture, a serous cavity, or parenchyma, it may more seriously inter- 
fere with the functions of the part ; and it may be more important to 
prevent, or restrain, or remove the effusion. Thus, in the submucous 
cellular texture of the glottis, or in the serous membranes of the brain, 
a little effusion may prove fatal ; and in the lungs or pleura, effusions 
are injurious in proportion to their extent. Besides the measures 
directed against determination and vascular distension, it is doubtful 
that we possess means of restraining effusion. It is pretty certain that 
some other antiphlogistic remedies, especially mercury and antimony, 
do diminish the effusions of inflammation, and promote their reabsorp- 
tion ; but it is not clear that they do so in any more direct way than 
by reducing the local and general excitement, or by their evacuant 
effect. The expressions, "sorbefacient," and "exciting the absorbents," 
hypothetically ascribe to remedies the property of increasing absorp- 
tion ; but nothing in physiology points out any direct mode in which 
absorption can be artificially increased. A free action of the excreting 
organs promotes absorption, by reducing the distension of the vascular 
system. Absorption is also promoted by a circulation that is free, with- 
out excitement or distension;^ and the return of the vessels to a healthy 
state is generally attended with more or less absorption of the effusions. 
It is probable that blisters and other counter-irritant applications near 
the inflamed part promote absorption, not merely as evacuants or 
derivants, but also by causing a rapid flow of blood through the adjoin- 

1 In my Gulstonian Lectures [Med. Gaz. July, 1841), I adverted to the effect of a rapid 
current in promoting absorption. Mr. Gr. Eobinson has since illustrated this effect by 
some experiments {Med. Gaz. May, 1813). Another influence Tvhich probably conti'i- 
butes, is the different density of the fluid within and without the vessels : that within is 
more dense and saline, and, by the law of endosmosis, tends to attract the thinner fluid 
from without. This explains the greater readiness with which the thinner effusions are 
absorbed. Can we increase absorption by rendering the blood more saline than usual '.' 
The thirst after taking salt food would seem referable to this cause : and the beneficial 
influence of salines in inflammatory diseases may be partly due to this mode of operation. 



280 PROXIMATE ELEMENTS OF DISEASE. 

ing vessels, which facilitates the endosraosis and removal of effused 
fluids. Hot fomentations and douches and stimulant frictions seem to 
operate in the same way. 

In various cases, it is necessary to give vent to the accumulated effu- 
sion by surgical operation, as by incisions or acupunctures in erysipelas, 
opening abscesses, paracentesis in empyema, &c. This is chiefly neces- 
sary where the effused matter is purulent and little susceptible of absorp- 
tion, as well as noxious to the system; but sometimes the mere quantity 
or situation of the effusion, by endangering life, renders the resource of 
an operation necessary, as in acute laryngitis and some cases of pleurisy. 

497. — 9. Increased absolution is manifest in the processes of soften- 
ing, ulceration, and suppuration. I have endeavored to explain how, 
in the midst of distended and effusing vessels, absorption is increased. 
The veins and lymphatics are free, and, by the motion communicated to 
them from the current of the neighboring and anastomosing branches, 
they are ready to convey away all the fluids that can pass through their 
coats. {^Gulstonian Lectures^ 1841.) In fact, this is doubtless a pro- 
vision for the removal of superfluous matter, old and new ; but the 
process becomes injurious and destructive when it predominates over 
effusion, and extensively invades the living textures. But we have 
found reason to suppose that textures do not fall a prey to the soften- 
ing or ulcerative process, unless their vitality is lowered and then- nutri- 
tion impaired by a defective supply or quantity of blood (§§ 466, 7) ; 
and that inflammation does produce these efiects very differently in 
different cases. Sometimes local stimulants and general tonics check 
softening and ulceration by improving the vitality and nourishment of 
the obstructed part ; but they may have the opposite effect if the circu- 
lation in the affected part is too much obstructed to admit of increase. 
Hence we find, in phagedenic ulcerations, stimulants sometimes check 
and sometimes aggravate the disease. The increased absorption which 
forms a part of ulceration might be arrested by diminishing atmospheric 
pressure on the part, as by applying a cupping-glass over a phagedenic 
ulcer ; but such an expedient is rarely practicable. 

498. — 10. Impeded circulation in the part has been just adverted to 
as contributing, with increased absorption, to the processes of softening 
and ulceration ; but its greatest effect is manifest in gangrene, or the 
complete death of the part. In suppuration, also, the part dies, but it 
is removed by absorption, and replaced by pus, which makes its way to 
the exterior. Of the few agents that may be directed to restore or 
improve obstructed circulation, heat is the chief one to be named. 
Heat enlarges vessels, especially arteries (§ 120), and facilitates the 
passage of blood through them ; and although, for this very reason, 
hurtful in sthenic inflammation and in parts where determination pre- 
vails, it is really very beneficial in the stages and forms of inflammation 
in which obstruction predominates and endangers the vitality of the 
part. Hence the utility of hot fomentations or poultices in low forms, 
or advanced stages of external inflammation. In slight cases, frequent 
applications of heat and moisture may entirely remove the obstruction, 
restore the circulation, and thus the life of the part, although the in- 
flammation may have already caused much effusion. In other cases, 



TREATMENT OF INFLAMMATION WITH FEVER. 281 

heat does not remove the obstruction, and therefore does not maintain 
the life of the part ; but by increasing the determination around it, it 
promotes its removal by suppuration, and it hastens and matures this 
process, which is the best by which a part, the circulation of which is 
obstructed, can be removed. In a similar way, too, heat favors the 
effusion of lymph, which circumscribes the suppuration and prevents it 
from spreading or infecting the system. Lastly, in a similar way, heat 
and other stimulating applications promote the process of separation or 
sloughing of a gangrenous part (§ 475), the whole circulation and life 
of which have ceased. These latter effects of heat may often be pro- 
moted by medicines and food calculated to maintain the vigor of the 
general circulation. 

499. — 11. The increased circulation around the obstructed part is 
often that constituent of inflammation which causes the most prominent 
symptoms, the greatest heat, pain, tenderness, and other marks of ex- 
cited function being commonly dependent on it. We have already 
noticed determination as an element of inflammation in its early stage, 
and refer to that clause (4) for an account of the remedies with which 
it is to be combated. We now advert to determination to the neigh- 
boriug vessels as a part of the extending irritation of inflammation, 
which often sympathetically excites the whole system into fever. The 
treatment, therefore, partakes of the character of that suited for inflam- 
mation with fever. 

Treatment of Inflammation with Fever. 

500. The fever excited by inflammation consists chiefly of the items 
mentioned in the table ; but it will be more convenient to notice them 
here together. They are — (12) Excitement of the heart and (13) of the 
arteries; (14) change in the blood by increase of fibrine, and (15) by 
diminution of the excretions. 

The addition of fever to inflammation very materially modifies the 
treatment. The disease then to be treated is not merely the inflamed 
part, and a few other parts in sympathetic relation with it, but the whole 
vascular system, its blood, and the secretions and functions which it sup- 
ports. In like manner, the treatment must now become general instead 
of local ; not because the local inflammation has lost its importance, but 
because it has now become a part of a general disease, which sustains 
it with such an energy that local remedies become trivial, or even inju- 
rious. Thus, when inflammation is backed by febrile excitement of the 
heart and arteries, the stimulant and astringent antiphlogistic remedies 
(§ 491) irritate the distended vessels instead of making them contract. 
What can local bloodletting do, when there is an excited force from be- 
hind impelling the blood to the inflamed part more rapidly than the ooz- 
ing by local bleeding can relieve it ? Derivants also have little power 
when the tension of the whole vascular system is so much raised. 
Counter-irritants must even prove injurious, by adding another cause of 
excitement to the system. So, too, narcotics can have no control over 
fever once established, and may prove hurtful by exciting the nervous 
centres, and still farther impairing the secretions (§ 166). Under these 



282 PROXIMATE ELEMENTS OF DISEASE. 

circumstances, a more general remedy is wanted, which shall reduce the 
action of the heart and arteries, and diminish the inflammatory character 
of the blood. The first and most powerful remedy of this kind is gene- 
ral bloodletting ; next come the stronger evacuants, antimony and 
mercury ; and loAvest in power are what are called refrigerants and 
direct sedatives. We shall briefly notice these antiphlogistic remedies. 
501. Bloodletting, if carried far enough, is sure to reduce the action 
of the heart ; for, as formerly explained, it may produce syncope (§ 70). 
A remarkable fact, first pointed out by Dr. Marshall Hall, is, that, in 
inflammatory disease, a much larger amount of blood may be drawn 
without producing syncope, than can be taken in health or in other dis- 
eases. The following is Dr. M. Hall's table of the results of his in- 
vestigation of the tolerance of bloodletting in diff"erent diseases. The 
numbers represent the mean quantity of blood which flows before inci- 
pient syncope in the sitting or erect posture': — 

I. Augmented Tolerance : — 

Congestion of the brain , . . . . . . ^xl — 1. 

Inflammation of serous membranes .... 

Inflammation of synovial membranes ..... \-^xxx — xl. 

Inflammation of fibrous membranes ..... 

Inflammation of tlie parenchyma of organs (brain, lung, liver, 

mammae, &c.) ........ 

Inflammation of skin and mucous membranes (erysipelas, 

bronchitis, dysentery) ...... 

II. Healthy Tolerance : — 

This depends on the age, sex, strength, &c., and on the de- l 

gree of thickness of the parietes of the heart; and is l-^xv. 



about 
III. Diminished Tolerance :- 

Fevers and eruptive fevers 



Delirium tremens and puerperal delirium . 
Laceration or concussion of the brain 
Accidents before the establishment of inflammation 
Intestinal irritation ...... 

Dyspepsia, chlorosis ...... 

Cholera ........ 



^^xi — xiv. 
§x— xii. 



Ev- 



\ I The explanation of the increased tolerance of bloodletting in inflam- 

i ' mation is, I apprehend, to be found in the increased excitability of the 

I '■ heart, and tonicity of the arteries, which maintain a sufficient force and 
3 tension to preserve the circulation, especially through the brain (§ 266), 
J ' even when much blood is lost. In asthenic or atonic diseases, on the 
j I other hand, the arteries being lax, and ill-fitted to transmit the blood, a 
I ' smaller loss is felt, and syncope may result. The variations between 
i '. inflammations occupying diff'erent scats, must be referred to the heart's 

I I strength, and the arterial tone being less augmented in some than in 
ji others; and are, therefore, indications of more or less sthenic (§ 477) 
j! character of the inflammation. The quantity of blood in the whole 

system will afl'ect the heart's action and arterial tension in a similar 
way ; and no doubt the more stimulating quality of the blood may con- 
tribute to the same results. 

r)02. The object of bloodletting in inflammation is not merely to 
p)-o(luce syncope, or a temporary impression on the pulse, but a perma- 



INFLAMMATION — TREATMENT — BLOODLETTING. 283 

nent reduction of the excitement of the heart and arteries ; and this is 
to be effected in different modes of bloodletting under different circum- 
stances. Where the inflammation is quite recent, and the fever has not 
existed long, a moderate amount of blood, rapidly taken from a large 
orifice, or from two arms at once, or even from the jugular vein, will often 
be sufficient to reduce the fever and inflammation. The circulation is 
thus reduced, perhaps, to syncope ; and, relieved of the pressure and 
determination of blood, the inflamed vessels soon recover their normal 
state, if not spontaneously, at least with the aid of some of the sub- 
sidiary antiphlogistic measures. The benefit resulting from this mode 
of bloodletting in recent cases is sometimes very striking, and the cure 
is effected at a comparatively small expense of blood. 

503. But the case is different when an acute inflammation and fever 
have lasted for two or three days. There is then not merely excitement, 
but sundry changes in the inflamed part and in the blood, which keep 
up the excitement ; the inflammation has become established in the part, 
and the fever in the system; and no brief impression on the circulation, 
however sudden and complete, can remove them. If in this state a 
patient be speedily bled to fainting, reaction will soon come on, and 
renew the fever with increased intensity. Here, therefore, it is neces- 
sary to bleed more slowly and to draw more blood; and instead of pro- 
moting the occurrence of syncope by the erect or sitting posture, it is 
proper to keep the patient in an easy recumbent or reclining position, 
and to watch for the good effect of the bleeding in the softening of the 
pulse, or the relief of the pain, or other distressing symptom. The 
actual occurrence of syncope is rather to be avoided, and may be pre- 
vented by untying the arm as soon as the lips lose their color, or the 
patient complains of feeling sick or faint. Thus practised, bloodlet- 
ting causes a more permanent reduction of the active elements of inflam- 
mation and fever, diminishes the exciting and too fibrinous condition of 
the blood, and, although it cannot repair the changes already produced 
in the inflamed part, it prevents their increase, and puts them in a 
condition favorable for the curative efforts of nature and the farther 
operation of other antiphlogistic remedies. In the more severe and 
confirmed cases of inflammation it is often requisite to repeat the blood- 
letting again and again; the indication for this being the return of 
incompressibility of the pulse, heat of skin, and a new aggravation of 
the symptoms. In all such cases, the advantage of the gradual over the 
sudden mode of bloodletting is apparent; for where the reducing influ- 
ence of this measure is longest sustained, it is least necessary to resort 
to it again. 

Another case in which it is expedient to draw blood largely rather 
than suddenly, is where inflammation is combined with plethora. On 
the other hand, in ansemic subjects, the blood should be economized as 
much as possible; the early depression from the loss of blood should be 
promoted by a posture favoring the occurrence of syncope, and might 
be sustained by the influence of antimony and other remedies. In some 
such cases, the temporary withdrawing of a portion of blood from the 
heart and large vessels, by means of the process of lisemo stasis, may be 
very beneficial ; by ligatures passed around one or more of the large 



284 PROXIMATE ELEMENTS OF DISEASE. 

limbs, more or less blood may be arrested in the limbs, and for the time 
mthdrawn from the current of the circulation (§ 31 8) ; this expedient is 
preferable to dry cupping, because it does not equally spoil the blood 
thus arrested. 

504. After the general excitement has been lowered or removed by 
Ijjj general bloodletting, the local inflammation often has to be treated by 
d\ topical bloodletting, which now is not only more efficacious in reducing 

■i; the determination and distension of the inflamed part, but contributes 

to keep down the general excitement. In fact, local bloodletting, as 
by cupping or numerous leeches, may be made so extensive as to be 
tantamount to general bloodletting; and the cases in which it has most 
of this efi'ect are those in which slow bleeding answers best. In either 
extreme of age, and in the feeble, local bleeding only is admissible. 
Local bloodletting is chiefly suitable for inflammations which are super- 
ficial and extended, as those of the pleura or peritoneum. It is of 
much less avail in pneumonia, cerebritis, and other inflammations of 
deep-seated or parenchymatous organs. 

505. Of other evacuants none are equal to purgatives, which are a 
great aid to bloodletting, and should be used in most cases of severe 
inflammation, uncomplicated with gastro-enteritic irritation. They ope- 
rate on so large a surface that they afi*ect the system, and their efi"ect 
may be pushed to the extent of producing syncope; but such an 
extreme result is attended with much exhaustion, and their continued 
use may cause intestinal inflammation. The chief benefit arising from 
purgatives may be obtained from a few efficient doses at the commence- 
ment of the treatment. These aid the depressing effect of bloodletting, 
remove feculent matter, which is often a source of irritation, and clear 
the intestinal canal for the operation of other medicines. The stronger 
and less heating purgatives are to be preferred, such as calomel, jalap, 
salts and senna, combined with tartar-emetic or colchicum. A combi- 
nation of several, which operate most on different parts of the canal, 
answers best. 

506. Of internal remedies against inflammation with fever, that which 
most resembles bloodletting in its effects, is tartarized antimony. It 
is far less sure in its operation, and its influence is not proportioned to 
the quantity; yet under its use, especially if preceded by bloodletting, 
the pulse becomes less hard and frequent, the heat of skin is moderated, 
and sometimes perspiration ensues, whilst the local symptoms are 
generally more or less improved. Sometimes it causes vomiting, more 
rarely purging; but its best antiphlogistic operation occurs where these 
eff'ects do not ensue to interfere with a continuance of the medicine ; 
and I have frequently found its utility most marked, when it did not 
cause even nausea or profuse diaphoresis. Tartarized antimony, and 
the milder preparation, James's powder, have been very long used, in 
this country, as febrifuge medicines; and Dr Marryatt, who practised at 
Bristol in the last century, prescribed the former in large doses in the 
treatment of inflammation. Tlie practice was since carried to a greater 
extent by Rasori, and other Italian physicians, who gave from 10 to 120 
grains in twenty-four hours. Lacnnec adopted the use of the remedy in 
more moderate quantities, giving from one to four grains, in some agree- 



INFLAMMATION — TREATMENT — ANTIMONY. 285 

able vehicle, every second or third hour for six doses; then intermitting 
or continuing it according to circumstances. In pneumonia and rheu- 
matism, he considered it the chief remedy. Most practitioners in this 
country now consider tartar-emetic a valuable aid in subduing inflamma- 
tion, chiefly to be used after bloodletting ; or in slighter inflammations, 
where bloodletting is inexpedient. I rarely find it useful to raise the 
dose beyond two grains every three hours ; and in most cases one grain, 
half a grain, or even less, will sufiice. The first doses sometimes 
cause vomiting ; but this generally subsides when the doses are repeated, 
and may be prevented by giving the medicine in a mild neutral saline 
draught, with from five to ten minims of the diluted hydrocyanic acid 
in it. Antimony acts most satisfactorily in inflammations of vascular 
parenchymata and complex membranes ; such as the lungs, the testicles, 
the mammae, the air-passages, the cellular membrane and skin, and the 
joints. It is less efi"ectual in inflammations of serous membranes, and 
would be unsafe in inflammatory aff'ections of the intestinal canal. It 
is most beneficial in the early stages of inflammation, especially when 
attended with fever ; and seems to have little efi'ect on the products of 
inflammation. 

How antimony operates in reducing fever and inflammation is quite 
uncertain. Rasori considered it to be a direct sedative or contro-stimu- 
lant, diminishing the excitability of the vascular system, and thus neu- 
tralizing the inflammation. He supposed that the tolerance or power of 
the body to bear large doses of the remedy, entirely depends on the 
presence of inflammation in the system ; but, as Laennec has observed, 
this is not correct; for although patients suff'ering from inflammation 
are less easily nauseated than others, yet after the inflammation has 
been subdued, those quite convalescent have continued to take 12 or 18 
grains daily without nausea, or loss of appetite. Laennec first considered 
that the medicines act as a revulsive, by irritating the stomach; but this 
view being made by the Broussaians a ground of opposition to the use 
of the remedy, Laennec latterly represented it to act as a sorbefacient. 
It seems to me that the most reasonable view to take of its opera- 
tion is, that it chiefly acts by diminishing the tonicity of the vascular 
system (§122). Small doses certainly relax the pulse and skin, and, 
where there is no fever, produce perspiration without stimulating. They 
also seem to increase the biliary and intestinal secretion. In inflam- 
mation and fever, larger doses are required to produce the same result ; 
and as soon as the excessive arterial tension is relaxed, the chief part of 
the fever is removed (§ 441). By thus reducing the increased tonicity of 
the arteries, the circulation is equalized and quieted, and the determi- 
nation to and distension of the inflamed part are diminished ; and the 
vessels generally are placed in the condition for their natural offices of 
secretion, which their extreme tension had before interrupted. It is 
quite possible that this operation of antimony, and another more directly 
exercised on the inflamed vessels, may be dependent on a chemical de- 
oxidating influence attaching to the protoxide of the metal, as before 
hinted at (§ 494), and this notion would account for the greater tolerance 
of the medicine under inflammatory disease, which involves a process 
of hyperoxidation. These views are, however, at present, no more than 



286 



PROXIMATE ELEMENTS OF DISEASE. 



i! 



hypothetical, and might with advantage be tested by experiments on the 
lower animals. 

507. Another great remedy in inflammation is mercury, alone or 
combined with opium. The combination of calomel and opium was first 
employed by Dr. Hamilton of Lynn Regis ; and the rules which he pro- 
posed for its use have hardly been improved on. After a sufiicient vene- 
section and a full purge, he gave from one to five grains of calomel with 
from one-fourth to one grain of opium every six, eight, or twelve hours. 
When much fever was present, with dryness of skin, he added tartar- 
emetic and camphor. If no relief ensued in twenty-four hours, vene- 
section was repeated. Most practitioners admit the power of this re- 
medy, although some ascribe its efficacy to the mercury, others to the 
opium ; and the proportions of each have been variously altered. The 
beneficial efi^ects of this remedy generally, but not entirely, depend on 
the mercury afi"ecting the system, as manifested in adults by the fetor of 
the breath, and the tenderness and swelling of the gums ; and in child- 
ren, by spinach-like evacuations from the bowels. Improvement is, 
however, often manifest before these results take place. In iritis, the 
influence of mercury is quite visible in removing efiused lymph ; and it 
thus obviously in some way promotes absorption, as well as prevents 
efiusion. The same " sorbefacient" operation is seen in the effect of 
mercury in removing the callous margin of indolent syphilitic ulcers, 
and in promoting the spread of phagedenic ulcers. Dr. Earre thinks that 
mercury destroys the red particles of the blood, and causes in the sys- 
tem a disposition to erythematic inflammation, which is incompatible 
with phlegmonous or plastic ; but this is opposed by the fact that 
lymph is thrown out, and granulations form, and healthy ulcers heal 
during mercurial action. It will be useful to give briefly a view of the 
operation of mercury and opium ; for although we cannot be confident 
as to its entire accuracy, yet it is founded on what is best known of the 
effects of these medicines, and may therefore be a guide in their admi- 
nistration. 

The opium is useful in preventing the calomel from purging, and es- 
pecially in subduing the nervous irritation attending inflammation, and 
which we have found to be one cause of that sympathetic excitement 
which, when complete, constitutes fever (§ 440). This salutary effect of 
opium alone is sometimes seen when the vascular excitement has been 
subdued by a large bloodletting, and in cases in which nervous irritation 
forms a chief element of the disease ; here, a full dose of opium will 
subdue the remains of the inflammation better than any other antiphlo- 
gistic remedy ; it seems to paralyze those sympathies which are concern- 
ed in renewing or maintaining the excitement of inflammatory fever. So, 
too, in combination with mercury, the opium exercises this narcotic in- 
fluence ; whilst tlic mercury prevents its astringent effect on the secret- 
ing organs (§§ 60, 173). The mercury acts farther ; it augments the 
biliary and intestinal secretions; sometimes inducing copious mucous and 
bilious evacuations ; and from its effect in iritis, it may be presumed to 
facilitate the solution and removal of effused lymph. How it has this 
effect is quite uncertain ; probably it is by changing the condition of the 
blood, by a diminution of the fibrine and white corpuscles, the increase 



INFLAMMATION — TREATMENT — COUNTER-IERITANTS. 287 

•of which is much concerned in contributing to the changes of inflam- 
mation. So we find mercury chiefly useful where the blood is very 
much bufi"ed, and there is tendency to copious fibrinous effusions as in 
inflammations of serous membranes and croup. Calomel and opium 
have little influence over high inflammatory fever ; and the system thus 
excited generally resists the mercurial action. This remedy has no 
farther sedative efi"ects than those which proceed from its action on the 
intestinal canal ; and, unless to produce this action, it is not well adapt- 
ed for the earliest stage and most active forms of inflammation. In 
these circumstances, bloodletting is more required with mercury than 
with antimony ; and if fever returns during the action of mercury, 
bloodletting or active purging may be necessary to reduce it. In fact, 
the operation of calomel and opium is less antiphlogistic, and more al- 
terative, than that of bloodletting or antimony; it is inferior to them in 
the power of reducing inflammatory fever and active inflammation, but 
it is superior to them in arresting and removing the more plastic products 
of inflammation. Besides this comparatively slow influence produced by 
mercurial preparations generally there are others more peculiar to calo- 
mel, which render it a most useful remedy even in active inflammations ; 
when given in large doses (from grs. v. to 3j) it acts as a powerful chola- 
gogue, and often causes the evacuation of dark-green matter, which, ac- 
cording to the examination of Dr. Gr. Bird, resembles the coloring matter 
of the blood rather than bile, in composition. This operation of calomel 
does in truth resemble that of bloodletting, being more actively antiphlo- 
gistic than that of small doses. This mode of exhibition has been much 
used in India, and in this country has been employed with much success 
by Dr. Chambers. The chief evil attaching to it, is its tendency to induce 
inflammation of the large intestines and dysenteric straining ; and for 
this reason it cannot be long persisted in. 

508. As considerable aids in the treatment of inflammatory fever, 
although quite inefficient alone, must be mentioned various saline medi- 
cines, such as nitrate of potass, and the alkalies combined with vegetable 
acids. Diluted solutions of these allay thirst, and seem to cool the fever ; 
hence they have obtained the title of refrigerants. It is uncertain how 
far they may operate in diminishing the cohesion of the corpuscles and 
excess of fibrine in the blood (§ 438) ; but we can distinctly trace their 
goodefi'ect in augmenting the secretions, particularly that of the kidneys 
(§ 256). They are all more or less diuretic ; and most of them also 
supply an alkaline base, which, by uniting to the lithic and lactic acids 
formed in the blood, facilitate the separation of these matters by the 
kidneys. Colchicum and digitalis are sometimes reckoned among anti- 
phlogistic remedies ; but in common inflammation, they are of very 
inferior power. In the absence of high fever, colchicum somewhat 
resembles mercury in its special action on the secretion of the liver, and 
it augments the elimination by the kidneys (§ 257) ; and digitalis acts 
as a diuretic, as well as a sedative on the irritability of the heart ; but 
during severe inflammation, these efi"ects are scarcely produced by doses 
which it would be prudent to administer. The same remark is applica- 
ble to hydrocyanic acid, and various preparations of aconite. There can 
be no question that both of these are capable of depressing the action 
of the heart, and thereby of reducing the force of the circulation; but, 



288 PROXIMATE ELEMENTS OF DISEASE. 

in order to have such an effect during the excitement of active inflam- 
mation, it would require large and dangerous doses. 

509. The utility of counter-irritants as a remedy for several elements 
of local inflammation has been already noticed (§§ 493, 496) ; but their 
operation is positively injurious in sthenic inflammation during the preva- 
lence of fever. They then add to the excitement of the system ; and in 
proportion to the inflammation "which they excite, they prove a new source 
of the inflammatory changes in the blood (§ 438). But after the fever 
has subsided under the influence of remedies, or is exhausted by time, 
the advantage of counter-irritants predominates. The seat of their 
application, too, ought to have regard to the excitability of the vascular 
system ; where this is great, the counter-irritation should be more remote 
from the seat of inflammation ; w^here the excitability of the vessels is 
much reduced, blisters may be applied in close vicinity to the affected 
part. Blisters and suppurating counter-irritants, which cause copious 
discharge, are the most useful ; tending to draw away the remains of 
inflammation, and to promote the removal of effused matters left by it. 
These become chief remedies as inflammation inclines to a chronic state, 
or where it has left such structural changes as cannot be speedily 
removed. 

510. The antiphlogistic regimen comprises the avoidance of all circum- 
stances and agencies capable of exciting or fatiguing the body or mind 
of the patient. Absolute rest in bed, in a very quiet, rather dark, yet 
cool and carefully ventilated apartment, is most favorable to the restora- 
tion of tranquillity to the circulation. The exclusion of noise, bustle, 
and other causes of excitement, and the careful removal of all irritating 
excrementitious matters must not be omitted. 

The antipJdogistic diet comprehends the same negation of all irritating, 
stimulating, and the more nourishing articles of food. The proteinaceous 
materials, meat, eggs, and in severe cases, even bread and milk are to 
be prohibited, as well as all oily nutriment, which tend to increase the 
heat of the body ; amylaceous, gummy, and saccharine matters may be 
taken sparingly, and are best exhibited in thin fluids, such as barley- 
water, tea, weak gruel, and arrowroot, and the like. The thirst gene- 
rally present suggests the need of diluents, which are farther useful in 
cooling the body, and in promoting the action of diuretic, diaphoretic, 
and other evacuant medicines; but even these, if used to excess, tend 
to oppress the stomach and disturb the heart's action ; and in cases of 
inflammation of the lungs and of mucous membranes, may prove hurtful 
by augmenting the bulk of the circulating fluid. When fever is pre- 
sent, the total loss of appetite is a sufficient guide to the necessary ab- 
stinence from food, and the stomach often will not retain or digest any 
but the weakest nutriment ; but this is not the ffict in all cases of in- 
flammation where the restraint may be equally called for. 

511. Exhaustion. Depression from Poison, — (Sec Table, 16 and 17.) 
The exhaustion ensuing after long-sustained excitement of inflammation 
and fever, often renders stimulants and tonics, as well as a generous diet, 
necessary in the after treatment; but the greatest circumspection is 
necessary, to be sure that these measures shall be proportioned to the 



REMOVAL OF THE PRODUCTS OF INFLAMMATION. 289 

wants of the case, and not pushed so early or so far as to rekindle the 
inflammation afresh, or to produce other disorder in the weakened organ- 
ization. No diffusible stimulant is more generally or safely applicable 
at this juncture than preparations of ammonia, which are conveniently 
exhibited by adding the carbonate of ammonia to the saline draught. 
It seems possible that its utility may partly depend on its supplying the 
azote necessary to convert amylaceous and saccharine nutriments into 
albuminous or gelatinous principles, according to a conjecture lately 
proposed by Dr. Alison. Alcohol and ether more obviously act by 
supplying a material for animal heat, which may also prevent the oxygen 
of the blood from preying too much on the materials of the textures. 
Similar aids are required, but are less successful, in supporting the system 
against the pernicious influence of purulent or gangrenous matter result- 
ing from the inflammation. Even in cases of suppuration, the occurrence 
of the premonitory rigors, the diminished strength of pulse and heat of 
skin, point out the time for changing the reducing plan for one more 
supporting ; but the degree to which the change is made must depend 
on the symptoms, and on the efficiency with which nature is attempting 
the process of limiting the destroyed part. When suppuration has com- 
menced, there is no probability of its retrogression ; and therefore the 
obvious indication is to promote its completion, and to prevent its exten- 
sion and the diffusion of the pus through adjoining parts and through 
the system. This indication is best fulfilled by local stimulants, espe- 
cially heat combined with moisture. This promotes determination of 
blood to the part, whereby the pus-globules are fully developed and the 
compressed fibrine and tissue dissolved and absorbed (§ 461), whilst 
surrounding vessels, inflamed but less obstructed, are throwing out a 
barrier of lymph, retaining its vitality and resisting the action and pro- 
gress of the pus in all directions, except that in which the textures yield 
most, and through which it finds vent ; this is promoted by various expe- 
dients described in surgical works. The local treatment of gangrene 
also requires more or less of the aid of stimulants to aid the process of 
separation or sloughing of the dead from the living parts. It is proba- 
ble that, in all cases, some purulent or some gangrenous matter finds its 
way into the circulation ; therefore, in addition to stimulants and tonics, 
antiseptics (such as chlorinated liquids, nitromuriatic acid, chlorate of 
potass and creosote), are sometimes with advantage given internally to 
counteract the septic influence ; and above all, the secretions are to be 
kept free to promote the elimination of the morbid matter (§§ 260, 443), 
the foul nature of which is often evinced by the fetor and disordered 
appearance of the feces and urine. For a similar reason, foul suppurat- 
ing and gangrenous sores are dressed frequently, and their discharge 
corrected and promoted by antiseptic and alterative applications. 

18. The Removal of the Products of Inflammation. 

512. The serum, liquor sanguinis, and the healthier kind of fibrine 

and exudation corpuscles (§ 424), are removed by the natural process of 

absorption (solution by conversion into tritoxide of proteine or other 

soluble products, and subsequent endosmosis into the adjoining vessels), 

19 



290 PROXIMATE ELEMENTS OF DISEASE. 

aided by various remedies before mentioned, particularly blisters and 
other counter-irritants, mercury, iodine, iodide of potassium, colchicum, 
and other diuretics. As a free circulation of blood probably promotes 
the removal of effused solids, partly by farther oxygenating them, the 
idea is suggested that we may aid this process by the internal exhibi- 
tion of agents which contain a large proportion of oxygen in loose combi- 
nation. Nitric acid answers to this description ; and whether this be one 
mode of its action or not, I can affirm, from much experience in its use, 
that it is the best medicine that I know for the state of convalescence 
from inflammations. In doses of 20 to 30 minims, three or four times 
daily, in some aromatic or mild bitter vehicle, it often cleanses the 
tongue, and improves appetite, circulation, and strength. Its utility is 
limited by its tendency to irritate the bowels, but this result is rare. 
Products of external inflammation are sometimes more speedily dis- 
persed under the influence of what are called discutients, which are gene- 
rally slight stimulant applications, such as a warm spirit lotion, or solu- 
tion of hydrochlorate of ammonia, common salt, or iodide of potassium : 
and, in more chronic cases, by friction with liniments containing mer- 
cury, iodine, ammonia, and spirit. These operate in various ways al- 
ready explained, by promoting a free current of blood through the part 
without distension, and thus facilitating absorption; by diminishing the 
atonic congestion left by inflammation; by promoting secretion or exha- 
lation; by pressure, &c. The restoration of a vigorous state of the 
circulation and excreting function is often necessary for the removal of 
copious effusions and deposits left by inflammations. Thus, I have 
noticed that pleuritic effusions frequently show no signs of dispersion 
until the strength of the body begins to return under a restorative mode 
of treatment. From the researches of Mr. Gulliver and others, it ap- 
pears that the longer an inflammatory product remains without becom- 
ing organized, the more does it abound in particles or granules of a 
fatty character, consisting of margarine and oleine. This change, which 
is like that of atheromatous matter in arteries, and aplastic tubercle, 
probably depends on a spontaneous conversion like that which occurs 
in the formation of adipocire from fibrine kept moist, and secluded from 
the action of the air. To prevent such a result, and, perhaps, to dis- 
perse it where begun, we naturally look to means which increase the 
free circulation of arterial blood in and around the part; which, either by 
its oxygen or other solvent agents which it contains, may dissolve away 
the solid fats, and assist to disperse the solid deposits. This subject 
will be reviewed under the head of Degenerations and Morbid Deposits. 



TREATMENT OF VARIETIES OF INFLAMMATION. 

513. The sthenic (§ 477) form of inflammation requires the whole 
array of antiplilogistic remedies to be directed Avitli energy against it. 
The prevalence of determination of blood, active vascular excitement, 
and the ovcr-fibrinous condition of the blood, demand the free use of 
bloodletting, calomel, purgatives, and antimony at the onset ; and the 



INFLAMMATION — TREATMEXT OF VARIETIES. 291 

ful] operation of mercury if the disease continue. In asthenic inflam- 
mation, on the other hand, bloodletting is ill borne, and often can only 
be practised locally ; and the chief treatment is with antimony or mer- 
cury, and blisters, which, in the absence of high fever, may be employ- 
ed at a much earlier period than usual. The diet, although light, must 
not be too spare, and may include such light nutriment as animal broths, 
milk, and farinaceous food. Mild stimulants may sometimes be required, 
especially ammonia, in order to enable the system to complete the 
processes of protection and elimination which are ever needed during 
inflammation (§§ 443, 4). 

514. Acute inflammation (§ 478) demands a very prompt use of the 
suitable antiphlogistic remedies ; but the choice made of them, and the 
extent to which they are to be pushed, will depend on whether the in- 
flammation be sthenic or not. Subacute inflammation is generally of the 
asthenic form ; and being less severe, as well as slower, in its progress 
and efi'ects, it does not require such active treatment. It must not, how- 
ever, be neglected; for its obscurity sometimes renders it dangerous; and, 
in an insidious manner, it sometimes seriously injures function and 
structure. Its long continuance, or liability to recurrence, renders it 
necessary to continue a moderate antiphlogistic treatment for several 
weeks. When lasting so long, it tends to become more asthenic, and 
the more lowering antiphlogistic remedies are no longer serviceable ; and 
sometimes it is proper even to call in the aid of tonics and improved 
diet, whilst the local inflammation is treated with counter-irritants. 
Mercury, with opium, is generally one of the most useful remedies in 
subacute inflammation. 

515. Chronic inflammation recedes still farther from the inflammatory 
type, and borders more on congestion or disease of nutrition. The ab- 
sence of fever generally supersedes the need of the stronger antiphlo- 
gistic remedies — those for local inflammation being sufiicient ; general 
bloodletting is needful only when plethora also is present ; and even 
local bloodletting should not be too freely employed ; for it weakens the 
system, which is generally already too feeble in chronic inflammation. 
Counter-irritants are more constantly useful; and their application should 
be varied according to the seat and extent of the inflammation. In in- 
flammations of serous membranes, a succession of large blisters answers 
best. For chronic inflammations of parenchymatous organs, and ulcer- 
ations of mucous membranes, counter-irritants, which excite pustules, 
or setons, are of more avail. Mercury is often useful, and so are other 
alterative medicines, especially salines, and the iodide of potassium. 
Mercury is more suitable to the more sthenic forms, attended with eff'u- 
sion of lymph, leading to tough thickening and induration of textures. 
Iodide of potassium is better adapted for chronic inflammation of an 
asthenic character, with reduced blood and strength, with tendency to 
ulceration, suppuration, or aplastic deposits. It is often requisite to keep 
up the general strength by the mildest tonics, such as sarsaparilla and 
mild bitters, and to allow a nourishing, but not stimulating diet, adapted 
to the digestive powers of the patient. Careful attention to the state of 
the excretions is particularly necessary. Courses of mineral waters and 



292 PROXIMATE ELEMENTS OF DISEASE. 

change of air by gentle travelling, are often serviceable in chronic 
inflammations. 

516. In congestive inflammation (§ 480), the treatment for congestion 
should be combined with that of subacute inflammation. If the subject 
be plethoric, general bloodletting would be proper ; otherwise local 
bleeding and various derivants or revulsives, among which cupping and 
dry cupping, or hsemostatic ligatures (§§ 818, 503) are the most efi'ectual. 
Rubefacient applications to an extensive surface, as large mustard poul- 
tices, and strong ammoniacal or mineral acid liniments, are of consider- 
able efficacy ; and their use can be renewed and varied daily for a long 
time. Mercury and antimony are both highly useful in the more active 
stage of congestive inflammations ; the former especially for inflamma- 
tions of the abdomen, the latter for those of the lungs. In the absence 
of much irritation, iodide of potassium, mineral acids, and even quinia, 
sometimes help to disperse the congestive part of inflammation. So, 
too, in secreting structures, as the liver, kidneys, and mucous membranes, 
various stimulants, which excite the secretion of the part, act in a 
similar way. In congestive inflammation, as in long-continued conges- 
tion, the blood sufiers from long stagnation in the affected part, and, 
being spoilt (§ 191), may prove a cause of contamination to the rest of the 
blood in the body. Hence the propriety of using the various depura- 
tive remedies which increase the excretions, &c., and of resorting to iron, 
quinia, and nourishing food during the convalescence. For farther 
particulars, see the treatment of congestion (§ 313, et seq.). 

517. The treatment of phlegmonous inflammation^ is generally that 
for the sthenic form. Erysipelatous inflammation being generally asthe- 
nic, is not benefited by active antiphlogistic measures ; and in some 
cases it is necessary to adopt quite an opposite treatment, by ammonia, 
wine, bark, &c. ; this is where the influence of the specific poison (§ 482) 
predominates. In other cases, the reaction against this influence is very 
vigorous and requires moderation. Generally, warm fomentations to the 
affected parts, a saline, sometimes with small doses of tartar-emetic, and 
keeping the secretions free, answer best at first, and are, in a few days, 
to be gradually replaced by ammonia or wine, and bark or quinia, with 
improving nourishment.^ A more decided counter-agent against the 
poison (as against other animal poisons) is a desideratum ; but scrupu- 
lous cleanliness in all points, and careful regulation of temperature and 
ventilation, are the best preventatives in hospitals and sick rooms, where 
the effluvia from sores or wounds is apt to engender the disease. Punc- 
tures and incisions, which relieve the inflamed part by the discharge of 
blood and serum, cauterization by nitrate of silver, which by exciting a 

1 This term is used licre in the sense in which Cullen employed it, as opposed to erythe- 
matic or cry.sii)ebitous. I mention tliis, because boils or furuncular infiammations are 
sometimes of an asthenic character ; and with them not unfrcquently the constitution re- 
quires support. 

2 I':rysipela8 of the head and scalp is that which falls commonly under the observation 
of the physician ; and although often attended with formidable symptoms, I have very rarely 
known it })rove fatal. All the cases (twenty in number) under my care at the hospital have 
recovered in a periofl varying from one to four weeks, under the general treatment recom- 
mended above, without any other local treatment than fomentations, where the patient likes 
them, yiiry rarely a leech or two to the tcmj)lc, and poultices to any succeeding boils. 



INFLAMMATION — TREATMENT OF VARIETIES. 293 

different inflammation, arrests the progress of erysipelas — and mercurial 
ointment, which is supposed to modify its character — are the chief kinds 
of local treatment that have been found useful. 

518. Pellicular or diphtheritic inflammation is usually of an asthenic 
character, little benefited by bloodletting, but chiefly to be counteracted 
by mercury, which is the suitable remedy for all inflammations effusing 
lymph; and by local astringents, or even caustics, which, by powerfully 
exciting the vessels, change their action. Thus nitrate of silver, in sub- 
stance and in solution, hydrochloric and diluted nitric acids (one part to 
three or four parts of honey applied with a brush), and finely powdered 
alum, have been used with advantage in diphtheritic sore throat. In the 
croupy inflammations of children, the most effectual remedies are calomel 
freely used, antimony, and certain expectorant or attenuant medicines, 
w^hich promote the more liquid secretions of the inflamed membrane. 
The aphthous inflammation of children is readily subdued by a solution 
of borax, or a weak solution of sulphate of zinc ; using, at the same time, 
magnesia and mild mercurial aperients to correct the secretions of the 
alimentary canal. 

519. Hemorrhagic inflammations (§ 484) are often of the congestive 
kind ; and the hemorrhage arises from the excessive distension of vessels, 
as in the hsematemesis that sometimes precedes gastritis, the bloody dis- 
charges of dysentery, and the hsematuria which occasionally ushers in 
inflammation of the pelvis and tubes of the kidneys (pyelitis). The he- 
morrhagic tendency exhibited in purpura, and sometimes combined with 
inflammation in lichen lividus, and ecchymosed erysipelas, I have often 
found connected with congestion and torpid action of the liver (§ 171), 
and accordingly benefited by mercurial and saline aperients, followed 
by nitric or nitromuriatic acid. 

520. Scrofulous inflamr)iation (§ 485) being generally asthenic, is little 
benefited by bloodletting or other active antiphlogistic measures. Its 
disposition to produce early cacoplastic and aplastic effusions, makes it 
important that it should be subdued, if possible, at an early stage, in 
situations where the formation of curdy pus or tuberculous matter would 
be injurious. In scrofulous inflammation of the lymphatic glands, 
warmth and moisture and discutient applications (solutions of muriate 
of ammonia, iodide of potassium, warm vinegar) are often useful in dis- 
persing the swelling before it comes to suppuration. In internal inflam- 
mations in scrofulous subjects, as of the lungs, glands, and joints, local 
depletion is generally advisable, followed by free counter-irritation, such 
especially as may cause an external discharge of pus. Dr. O'Beirne 
and others recommend a free mercurial course for scrofulous inflamma- 
tion ; but this I consider admissible only in the earliest stage of the dis- 
ease, and in its more active forms ; for I have found (what I believe is 
the experience of most practitioners) that mercurialization greatly injures 
the constitution of scrofulous subjects, degrades the products of inflam- 
mation, and promotes softening and ulceration in textures where deposit 
has already taken place. It seems to me that it is rather asthenic or chro- 
nic inflammation (§ 4T9), in subjects that are not scrofulous, that is 
beneflted by mercury, and not that especially occurring in the scrofu- 
lous diathesis. Preparations of iodine, especially the iodide of potas- 



294 PROXIMATE ELEMENTS OF DISEASE. 

sium, do sometimes appear to countervail low scrofulous inflammation ; 
and their commonly salutary operation on the constitution renders them 
eligible medicines in scrofulous subjects. 

But the source of the peculiarities of scrofulous inflammation, and 
therefore the chief object for peculiar treatment, is the scrofulous diathe- 
sis, or constitution ; and as this seems to consist in a degraded condition 
of the plasma, or nutritive material of the blood (§ 211), often connected 
with a deficiency of red particles (§ 185), an invigorating and nourish- 
ing treatment and regimen are especially indicated (§§ 218, 219), and 
may sometimes be employed even when low inflammation is present ; 
this being counteracted by counter-irritation or other local antiphlogistic 
measures. Hence the best remedies in scrofula are tonics, nourishing 
diet, and other means calculated to improve the nutritive function and 
general health. Even the medicine that has attained the highest repute 
in the treatment of scrofula, may be considered as belonging to the class 
of nutriments. I allude to the cod-liver oil, which has long been em- 
ployed on the Continent, and in a few places in this country, and was 
highly recommended in a monograph. published by Dr. Hughes Bennett, 
in 1841. Its general adoption has, however, chiefly depended on the 
ascertained fact that it is equally efficacious when purified by animal 
charcoal, which removes from it its off*ensive taste and smell, which are 
great impediments to its being borne by patients. Commencing with a 
dose of a teaspoonful thrice daily (two hours after each meal), and gra- 
dually increased to a tablespoonful, this medicine has produced in many 
scrofulous patients such improvement as quite to astonish me. It seems 
to give a new impulse to nutrition, for an amendment in flesh, color, and 
strength soon attends its use ; commonly, the pulse is moderated, and even 
the appetite augmented, whilst more or less amelioration is generally 
manifest in the local inflammation. Thus scrofulous swellings diminish 
and even disperse ; enlargements of joints are reduced ; ichorous sores 
secrete a more laudable pus ; the profuse discharge from abscesses and 
vomicae is lessened; and consequently hectic fever, night-sweats, &c., 
are checked. The chief impediment to its use is its disordering the 
stomach and liver ; the latter I have sometimes found to be remarkably 
enlarged during its exhibition. The utility of cod-liver oil in tuber- 
culous disease, and. its mode of action, will be considered under the head 
of cacoplastic and aplastic deposits. Of other medicinal agents, the 
iodides of potassium and iron, other preparations of iron, bitters with 
alkalies, bark, or quinia, and mineral acids, have been found the most 
serviceable. Equally important in the treatment are pure and mild air, 
especially near the sea or on mountains ; warm clothing ; regular ex- 
ercise, friction, and other means to promote the superficial circulation ; 
warm sea-bathing, or cold, when borne (§ 79), followed by friction ; a 
good proportion of wholesome animal food, with due regard to the state 
of the excretions. These measures are of great efficacy in the scrofu- 
lous diathesis, and are often useful even after inflammation has pro- 
duced disease ; for they do much to prevent its increase, and assist 
nature in removing, or rendering inert, the cacoplastic or aplastic mat- 
ter. 

521. The peculiarity in the treatment of rheumatic and gout?/ in- 



INFLAMMATION — TREATMENT OF VARIETIES. 295 

flammation consists cliiefly in the use of means calculated to eliminate 
the morbid matter, which is its cause (§§ 251-254), from the system. 
The remedies which best promote this object have been already mentioned 
(§§ 252, 254). But it must be remembered, that the inflammation and 
fever excited may be so high and sthenic as to require active antiphlo- 
gistic measures before colchicum or mercury can be made to act ; and 
this is particularly the case in acute rheumatism, in which inflammation 
is excited in many parts at once ; and probably as a consequence (§ 438), 
the blood becomes surcharged with fibrine. Here general bloodletting 
is necessary, not to remove the cause of the inflammation, but the in- 
flammation itself. If, after bloodletting, the rheumatic cause abound 
still in the blood, which is commonly the case, it is proper then to give 
colchicum with alkalies, or iodide of potassium, or nitre in large quan- 
tities much diluted (Gendrin), and to continue such remedy for some 
time, until the morbid matter shall have been sufficiently eliminated. 
In asthenic cases, the use of bark, quinia, or other tonics may be 
serviceable, in improving the tone of the vessels after the irritation and 
exhaustion which the disease and its treatment have produced (§ 174). 

The infectious character of gonorrhoea and syphilis proves the specific 
nature of their cause ; but it is only of the latter that we can speak of 
a specific remedy. How mercury cures syphilis is quite uncertain. It 
is not by any property directly destructive to the virus ; for the disease 
cannot be prevented from appearing by mercurial action ; and when pre- 
sent, it is not always cured by it. It is more probable that mercury 
acts as an alterative, by removing the callous indurations of syphilitic 
sores and swellings, and by increasing the secretions, and thus gradually 
eliminating the syphilitic virus from the system. It is now well known 
that other remedies, which promote absorption and secretion, also pro- 
mote the cure of syphilis, especially the iodide of potassium. Gonor- 
rhoeal inflammation generally tends to a spontaneous cure in a few weeks' 
time ; but this may be accelerated by mild antiphlogistic and demulcent 
measures at first, and astringent injections and terebinthinate remedies 
subsequently. 



296 



CHAPTER lY 



STRUCTURAL DISEASES, OR DISEASES OF NUTRITION— ULTIMATE AND 
PROXIMATE ELEMENTS. 



SECTION I. 

NATURE AND CLASSIFICATION. 

522. Although we have had frequent occasion to advert to the 
changes in the process of textural nutrition effected by inflammation, 
congestion, &;c., and although nutrition might be included under the head 
secretion (§ 178), a primary element, yet it has seemed better to defer 
the notice of diseases of nutrition until now ; both because the previous 
consideration of disorders of the blood and its vessels gives the best in- 
troduction to them, and because we cannot strictly distinguish structural 
disease into ultimate and proximate elements. By analogy, indeed, we 
might infer that ultimate structural disease is that which affects element- 
ary structures singly, such as muscular fibre, nervous matter, cellular 
texture, &c. ; but we find structural disease rarely to be thus confined 
to one anatomical element, but rather to affect structures as they exist 
combined in more or less complexity. 

It will not be consistent with the plan of this work to give full details 
of structural disease, which belong rather to the department of morbid 
anatomy. It will be sufficient for our purpose, to notice the chief forms 
of diseases of structure, by tracing them through the alterations in the 
function of nutrition which produce them. This method will enable us 
to class these diseases in an arrangement corresponding with that applied 
to the elerfients of functional disease (§ 104), and under each head to 
state briefly what is known \vith regard to their nature and origin, and 
the remedies which influence them. 

As in the case of functional diseases, so of structural lesions, which 
are modifications of the function of textural nutrition, they may be 
comprehended under the three heads, increased^ diminished, and per- 
verted nutrition.^ 

' Although consitlcraljlc advnnccs liavel)een made inpatholof2;ical anatomj^ and several 
new works devoted to the sul)ject liave appeared since tlie publication of tlie first edition 
of tliis treatise in 1H4.3, it is satisfactory to me to find that in no material points has the 
advance of knowledge superseded the views there given of the elements of structural 
disease, but in many instances these views have been signally confirmed and extended. 
Under these circumstances, I have added to, rather than modified the text ; and, in pre- 



NUTRITION, AND ITS VARIETIES, 



29T 



ELEMENTS OF STRUCTURAL DISEASE. 



[ Increased = hypertrophy. 
Diminished = atrophy. 



DISEASED 
NUTRITION 



f Induration. 
I Softening. 
Transformation and degeneration. 



r 



Euplastic 



ALTERED 
MECHANISM 



I Perverted 
I 



f Contraction 
I Dilatation 
J Obstruction 
' Compression 
Displacement 
Rupture, &c. 



Deposits-} Cacoplastic 



Aplastic 



J Cicatrices. 
( False membranes. 
f Cirrhosis. 
j Fibro-cartilage. 
I Gray tubercle. 
[Atheroma, &c. 
r Yellow tubercle. 
\ Calcareous matter, &c. 



[_ Growths 



^.°^- , I Tumors. 
^^^^g^^^M Hydatids, &c. 

{Carcinoma. 
Encephaloma. 
Melanosis, &c. 



It must be remembered that the division here given, simple as it is, 
is too precise to be rigidly applicable to many cases. Lesions of nutri- 
tion often graduate into each other, and are very commonly combined: 
hypertrophy of some textures frequently coexisting with atrophy of 
others, perverted nutrition being often combined Tvith excessive or de- 
fective, and several of these different changes often occurring in succes- 
sion in consequence of the operation of the same cause. We have 
already found this to be the case with the results of inflammation (§ 479) ; 
and inasmuch as that process exaggerates the changes of nutrition, it 
has furnished us with many examples of the production of structural 
lesions. What we now have to notice are those changes which take 
place independently of distinct inflammation, and which are mere modi- 
fications of the process of nutrition or reparation which is continually 
going on in the textures of the living body.^ 

523. As in inflammation, so probably in the ordinary process of 
nutrition, the material of which most of the organized solids are formed 
is the fibrine of the blood. This, by the formation of nucleated cells 
or nuclei of fibres, constitutes the basis of textures, which are after- 
wards farther modified by growth and multiplication, and by the depo- 
sition of homogeneous or hyaline matter in their interstices. Some 
structures are chiefly formed of the nucleated cells pressed together and 
consolidated in rows and layers, as in the epidermis and the epithelium 

ference to new classifications and uncouth nomenclature, which it has been attempted to 
introduce from various foreign writers, I have retained my former division of the elements 
of structural disease, designated by terms in common use among British pathologists. 
For farther valuable information on details of morbid anatomy, I would refer to the works 
of Rokitansky, Yogel, and Lebert, especially that of Vogel, which Dr. Day has very ably 
edited for English readers. [Phih, reprinted, 1847.] It is much to be regretted that 
Rokitansky" s work has not been rendered likewise accessible ; for he seems to me to be the 
most accurate and experienced of all Continental morbid anatomists. 

' For an able summary of our present knowledge on the subject of nutrition, see Dr. 
Carpenter's Human Physiology. 5th ed. [chap. xi. p. 546.] 



298 STRUCTURAL DISEASES. 

of mucous membranes. In other textures, either cells are elongated 
into fibres, or primary fibres are developed in the blastema, as in fibrine ; 
this seems to be the mode of development of filamentous, areolar, or 
cellular texture and its modifications, serous and basement membranes, 
fibrous and tendinous structures. In cartilage, the chief materials are 
peculiar cells contained in an amorphous solid, or an organized fibrous 
substance; in bone, radiated earthy particles occur in the place of cells. 
In the first formation and growth of textures, the production and multi- 
plication of cells or nuclei from the plasma of the blood is necessary ; 
and it is interesting to observe that in young animals, in pregnant 
females, and in the subjects of inflammation, the colorless corpuscles in 
the blood (§ 212), which probably are cell-germs, are much more nume- 
rous than usual (§ 418). But in the ordinary textural nutrition of adult 
animals, there is less need of the formation of new cells or germs; those 
already existing in the texture maintain the process by drawing nourish- 
ment from the blood-liquor, which furnishes the materials of all the 
solid textures ; the formation of new cell-germs thus normally diminishes 
as age advances, and when then increased, it is usually the result of dis- 
ease. Nutrition in all its stages is probably more or less a vital pro- 
cess : for although the chemical and physical formation of nuclei or 
cell-germs admits of imitation by the operation of minute granules of 
fat, or an albuminous fluid undergoing oxidation (§ 211), yet their pro- 
gressive development, their growth into cells, their power of separation 
or secretion of certain matters from the blood-liquor, their power of 
self-preservation and reproduction, all are properties peculiar to living 
matter, and as such are to be regarded as ultimate facts or elements in 
physiology. When their laws shall have been more fully studied, we 
may hope to trace to these elements, varied in proportion and kind, 
corresponding elements in pathology, which will explain much that is 
at present obscure in the origin and nature of structural diseases. And 
we can already perceive, in a defect of these attributes of life, an element' 
of malnutrition, in which the vital process of development fails in one 
or more of its stages, and renders the material unfit to form part of a 
living texture. 

524. As nutrition depends on the blood for its material, and on the 
supply of arterial blood for the activity of the process, so it may be 
anticipated that changes of nutrition commonly arise from difi'erences 
in the quantity and quality of the blood, and from variations in its 
arterial character. Hence diseases of nutrition are usually connected 
with diseases of the circulation and of the blood (§ 279), a moderately 
active circulation, and a rich blood favoring nutrition ; a poor blood 
(§ 260), and either too active or too feeble a circulation, impeding it ; 
and a diseased quality or proportion in the elements of the blood (§§ 186, 
211) rendering it depraved. These causes operate on the whole frame; 
but they commonly affect some textures more readily than others, be- 
cause the process of nutrition is naturally more accive, and therefore is 
more speedily influenced in some than in others. Thus, fat and cellular 
texture are increased or diminished sooner than muscle, muscle sooner 
than tendon or bone, &c. ; and, for similar reasons, degenerations and 
other changes of structure affect some parts more than others (§ 311). 



INCREASED NUTRITION — HYPERTROPHY. 299 

But structural diseases are more commonly partial from causes existing 
in the part; and no causes are more common than those which aifect the 
circulation of the part; so that partial anaemia, congestion, determina- 
tion of blood, and inflammation are the most frequent causes of partial 
structural disease. We have made a similar remark of diseased secre- 
tion (§ 159) and other elements of disease. If the nervous influence 
aifects nutrition, it is probably through its operation on the circulation 
of the part. Thus a paralyzed limb wastes, because, not being exercised, 
it is not so freely supplied with blood. The muscles of the limb of a 
frog, the nerves of which are divided, lose their irritability and waste 
also ; but Dr. John Reid has shown that, by exercising these m.uscles by 
electricity, which promotes the circulation, both their irritability and 
nutrition are maintained. 



SECTION II. 

INCREASED NUTRITION — HYPERTROPHY. 

525. Hypertrophy, as a disease, is always partial; for, although the 
whole body in cases of obesity acquires an enormous bulk, this is from 
the extraordinary growth of the adipose tissue, a part only of the frame. 
When the nutrition of textures generally has reached the acme of full 
health, there is no more increase, and the superfluous nutriment accu- 
mulates in the bloodvessels, causing plethora (§ 276). 

[Although the development and growth of the body cease, as a gen- 
eral rule, at or about a determinate period — when the natural struc- 
tures and full stature are attained — still, some parts grow to the latest 
periods of life, unless interfered with by disease. This is especially 
true of the heart and arteries. Dr. Clendinning and M. Bizot have 
shown, not only that the heart enlarges with advancing years, though 
with a decreasing ratio of increase, but that its weight augments, and 
the thickness of its walls increases, and it thus acquires power in the 
same proportion as it acquires bulk. Every part, too, throughout life, 
has the ability to grow, according to its needs, in proportion as its func- 
tion is discharged. So long as the ordinary conditions obtain, after 
the attainment of the average size, each part merely assimilates; but 
when the conditions alter, and a part is necessarily more than usually 
exerted, it then manifests the ability of accelerating its growth — a re- 
serve power of growth and development, put forward in moments of 
emergency. 

The term hypertrophy is now used to designate excessive natural 
growth, unattended with the formation of any unusual product. Still, a 
distinction is to be observed between the increase of an organ by the 
uniform grotvtJi or enlargement of all of its tissues, and the increase by 
excessive development of some one. We have an example of the for- 
mer in the thickening of the epidermis under the influence of pressure, 
friction, and other external forces. For though its rate of waste is 
augmented, it does not grow thin, but thicker, until it is completely 



300 STRUCTURAL DISEASES. 

adapted to protect the cutis from the greater sources of injury to which 
it may be exposed under new circumstances. It puts forth its reserve- 
power, which is sufficient not only to repair all amount of waste but also 
to increase the quantity of the tissue to the amount required for the 
discharge of its increased functions. We see the same thing in the 
other tissues, particularly the muscles; as in a heart, for example, in 
which, from obstructed valves, the blood is held back in the organ; and 
the heart or one of its cavities necessarily acts with additional force. 
But, although the waste of an organ is commensurate to its exercise, 
there is no diminution of size, but, on the contrary, increase, or hyper- 
trophy. But a part may do more than grow; it may develop itself, or 
acquire new structures for new functions it maybe called on to perform. 
Examples of this are seen in the pregnant uterus, or when it is the seat 
of fibrous tumors; in the gall-bladder; or an obstructed ureter. 

According to Mr. Paget, the conditions which give rise to hyper- 
trophy, are three, namely : 1. The increased exercise of a part in its 
healthy functions. 2. An increased afflux of healthy blood. 3. An 
increased accumulation in the blood of the particular materials which 
any part appropriates in its nutrition, or in secretion. Examples of the 
first kind are furnished by the muscular system, particularly those of 
organic life — as the enormous thickening of the muscular fibres of the 
urinary bladder in cases of strictured urethra. 

The increased afflux of blood to a part may be the cause, as well as 
the consequence of hypertrophy. The transplantation of the spur of a 
cock to the highly vascular com'b is followed by the very rapid growth 
of that organ. The increased determination of blood to a bone, in con- 
sequence of partial necrosis, may give rise to hypertrophy of the entire 
bone. 

The third cause is illustrated by the rapid increase in size of the kid- 
ney, when its fellow is incapacitated from performing its function. 

For much valuable information on this subject, the reader is referred 
to the lectures of Prof. Paget,^ which we have followed in the preceding 
remarks. — C] 

Hypertrophy may affect individual textures or ivliole organs composed 
of many textures ; in the former case, it may be called simple hyper- 
troplcy (an ultimate element of structural disease) ; and in the latter, 
compjlex Itypertropliy (a proximate element). Let us mention a few 
examples of each. 

52G. Muscles become enlarged by full exercise alternated with suffi- 
cient repose, and a healthy and well-nourished condition of the blood. 
This increased development in the voluntary muscles cannot be called 
disease ; but I have seen it occur in the sterno-cleido-mastoid muscle, 
long tlic seat of convulsive motion ; and, by giving too great power to 
the muscle, it seemed to perpetuate the distortion. The best cure for 
this would have been Dieffenbach's operation of dividing the muscle, as 
in the case of squinting, in which certain muscles gain too much power 
and probably bulk. But muscular hypertrophy is chiefly morbid when 
it affects involuntary muscles. Thus, in the heart, it results from con- 

' Lectures on Nutrition, Ilypcrtropliy, and Atrophy. — Land. Med. Gaz. 1847. 



INCREASED XUTRITIOX — HYPEETROPHY. 301 

tinued excitement in sthenic subjects: and from the violence with which 
the enlarged heart moves and propels the blood, it produces various bad 
consequences. The muscular fibres of the bladder become hypertrophied 
in case of enlarged prostate, or other cause of difficult micturition; 
those of the stomach are so from stricture of the pylorus; those of the 
bronchi become so in spasmodic asthma, and dyspnoea is the result. 
In these examples (as in all others of true hypertrophy), there is an 
increase of the amount of the proper tissue, that is, muscular fibres ; in 
what mode these are produced, whether by new formation of cell-germs 
and subsequent elongation into fibres, or by splitting and growth of the 
original fibres, has not been ascertained. 

527. Hypertrophy of the interstitial filamentous textures of the lungs, 
liver, &c., occurs after long-continued congestion from disease of the 
heart, &c. (§ 311). In the cellular texture of the lower extremities, it 
appears to be a chief constituent of elephantiasis. Hypertrophy of the 
epidermis occurs in callosities of the skin, and corns, from continued 
irritation or pressure, which causes determination of blood to the part. 
Another form of hypertrophy of the cuticle is that arising from chronic 
inflammation in psoriasis, chronic eczema, and impetigo. The cuticle 
is here retained, and, from its stifi"ness, it often cracks into chaps, or rha- 
gades. In the more temporary or more superficial cutaneous flushes, 
congestions, or inflammations of erythema, scarlatina, lepra, and pityria- 
sis, the superfluous epidermis is thrown off in a peeling of the skin, or 
in detached scales. But ichthyosis presents the most extraordinary in- 
stance of hypertrophy of the epidermis, its scales accumulating in a 
solid state, so as to form scales, or coarse bristle-like projections. These 
affections of the epidermis have their parallels in diseases of mucous 
membranes; but the secretions of these membranes being fluid, the nu- 
cleated cells, which on the skin would form solid scales, here are thrown 
off in the mucus, which presents an increased number of epithelium 
scales, as well as the mucous cells and a viscid amorphous fluid (§ 455). 
Such disordered secretion of the mucous membranes not unfrequently 
coexists with cutaneous diseases; thus, bronchial congestion with viscid 
secretion occurs in persons affected with psoriasis and lepra. 

528. Complex or liypertrophy of organs of a healthy kind may result 
from a more copious flow of blood to them, contingent on their increased 
use. Thus, the uterus becomes hypertrophied in pregnancy; the breasts 
during lactation; one kidney becomes enlarged when its fellow is inca- 
pacitated by disease. The brain is more developed in proportion to the 
active exercise of the mind; and when this is carried too far, if inflam- 
mation, congestion, or some other vascular disorder do not occur, the 
brain may become hypertrophied, and by its bulk being too great for its 
bony case, it compresses the vessels, becomes indurated, and, as an 
obvious consequence, its functions are more and more impaired. Thus, 
in young subjects, who have been remarkable for precocity and activity 
of intellect, the brain has been over-nourished, and fatuity and coma 
have been the result. Mucous and cutaneous follicles sometimes acquire 
an extraordinary development after continued excitement, or without 
any such obvious cause. Bursse become enlarged in situations exposed 



302 V STRUCTURAL DISEASES. 

to much pressure or friction, as on the shoulders of porters, the knees 
of housemaids, the elbows of miners, and the ankles of tailors. 

The hypertrophy of the liver and spleen in protracted ague, may per- 
haps be referred to the frequent repetition and long continuance of the 
enormous congestions which this disease induces in these organs (§ 310). 
I have known a similar enlargement ensue after prolonged exposure to 
cold and wet. But in some cases, no such external cause can be traced; 
but the hypertrophy must be referred to a peculiar condition of the cir- 
culation of the affected organs, or to an unusual activity in their nu- 
f* ■ trient molecules. To this obscure category may be appended the case 

of enlargement of the thyroid gland in bronchocele. 

The fatty enlargement or hypertrophy of the liver, and of adipose 
|'= texture, may in many cases be referred to the reception of a large 

quantity of fat through the food, or a defective performance of those 
functions by which fat is eliminated from the system (§ 224) ; and in 
all respects the increase of fat may be viewed as less indicative of vital 
activity of nutrition, than of a predominance of its chemical material 
in the blood. 

529. The treatment of hypertrophy must depend on the pathological 
cause which induces it. In most cases, this cause is some variety of 
hypergemia, and the treatment suitable for the variety is to be employed 
(see Congestion, Determination of Blood, and Inflammation). But some 
remedies seem especially calculated to counteract the hypertrophy which 
these elements induce ; such are iodine and its preparations, mercury, 
alkalies, and, in the more sthenic cases, sedatives and evacuants, together 
with low diet. The same remedies are occasionally useful also in hyper- 
trophy less distinctly connected with hypercemia, as bronchocele. In 
all cases, it is proper to attempt, as much as possible, to remove or 
counteract the exciting causes of hypertrophy, as by tranquillizing the 
circulation in hypertrophy of the heart ; by soothing irritations of the 
stomach, bladder, (fee, in obstructive diseases of these viscera ; removal 
from malarious districts in case of visceral enlargements, &c. 



SECTION III. 

DIMINISHED NUTRITION — ATROPHY. 

530. Atrophy, unlike hypertrophy (§ 525), may be a general disease; 
that is, all parts of the body may waste so much as to impair their func- 
tions. General atrophy, marasmus, or emaciation^ consists in a re- 
moval of a considerable amount of the textures by decay and absorption, 
without a sufficient reparation by nutrition (§ 523). The organic mate- 
rials of the body are not persistent, but are more or less prone to decay, 
becoming effete or worn out in a limited period of time ; or as Dr. 
Alison expresses the same fact, the vital aflinities which hold them 
togctlier cease, and tlicy become obedient to common chemical affinities 
which tend to their dissolution ; the oxygen conveyed into the blood in 
respiration being a chief instrument in their decomposition. But in 



DIMINISHED NUTRITION — ATROPHY. 303 

the healthy body there is a reparatory process continually countervail- 
ing this decay, by the deposition of new materials whose vital affinities 
are energetic, and able to maintain the integrity of the textures (§ 523). 
Hence the causes of atrophy may be divided into the circumstances 
which promote decay, and those which impair or prevent reparatory 
nutrition. Among the former, may be counted various influences which 
greatly reduce the vital powers, such as excessive and prolonged exer- 
tion or excitement, want of sleep, extreme anxiety of mind, or con- 
tinued suffering ; under any of these, a person is familiarly said to be 
''worn to a shadow," without any more distinct disease taking place. 
But on examining the urine in such cases, it will often be found to con- 
tain an excess of urea, resulting from the decay of textures. This 
secretion is also sometimes alkaline, and unusually prone to decompo- 
sition ; and the intestinal and cutaneous excretions sometimes exhibit 
an uncommon fetor, arising from the same tendency to putrescence. 
A fever of a low or hectic kind may be excited as a secondary result 
of these changes, and this fever is mistaken for the cause of the wast- 
ing. In cases of marasmus from excessive secretions or drains from 
the body, there is often also proof of accelerated decay ; thus, diabetes 
mellitus reduces the body, not only by perverting and draining off its 
nourishment (§ 255), but also by promoting the decay of textures, which 
is manifest in the increased amount of urea excreted. Fevers and 
various acute diseases, attended with much excitement, in like manner 
exhaust the vitality of the textures and promote their decay, which 
takes effect especially as the disease declines, when the emaciation 
becomes most obvious. 

The circumstances which impair or prevent reparatory nutrition are 
several, and may occur in any or all the steps of the nutritive process, 
from the reception of food into the system, to its appropriation and assi- 
milation to the living textures. As examples in this series may be men- 
tioned : 1. Defective quantity or innutritions quality of food (§ 58, et 
seq.); 2. Disorder of some part or parts of the digestive apparatus, such 
as extreme dyspepsia, diarrhoea &c., which prevent the formation of 
chyle; 3. Diseased mesenteric glands or tumors obstructing the thoracic 
duct, intercepting the supply of chyle to the blood; 4. Perversion of the 
assimilating process by which chyle is converted into blood (§ 253), as 
in diabetes mellitus and chylosus ; 5. Defect in the formation of fibrine 
(§ 196) and albumen (§ 221j of the blood, the materials of nutrition; so 
that, instead of becoming the plastic material for repairing the texture, 
they have a tendency either to pass into decomposition, as in malignant 
fevers^ (§ 257), or to concrete in a cacoplastic or aplastic form, as in 

1 My friend, Dr. Hodgkin, considers a suspension of textural nutrition to be a cMef 
cause of the phenomena of fever, and has verj ingeniously applied this notion to explain 
many of the symptoms. — Lectures on Morbid Anatomy of Serous and Mucous Membranes, 
vol. ii. p. 490. Pvokitansky, and other German pathologists, consider that typhoid ferers 
depend on the production, in the body, of an organic matter having some resemblance to 
malignant formations. To this, they apply the term typhus-material, and indicate the 
follicles of the intestines, and the parenchyma of the lungs, as the chief places of its 
deposition. Under the microscope, hovrever, this matter exhibits nothing to distinguish 
it from bad fibrine or cacoplastic lymph ; and in accordance vrith the vie^ in the text, I 
consider it to be such, and tending to inyolve in a process of sloughing the excretory 



304 STRUCTURAL DISEASES. 

tuberculous diseases ; 6. Excessive discharges of various animal fluids, 
of blood, pus, serum, milk, semen, mucus, &c. ; or morbid growths, which 
monopolize the nourishment of the body, such as tumors of various 
kinds, particularly cancer ; 7. Parasitical creatures, such as hydatids, 
worms, &c. 

531. A consideration of the above list of causes of emaciation, 
will show how uncertain it is as a symptom if it be taken alone ; but 
when traced to its cause, it is a very important index of the amount to 
which that cause operates on the living body. Emaciation will rarely 
continue or advance to an extreme degree, without structural changes 
which render the cause permanent ; hence, extreme marasmus is gene- 
rally connected with tuberculous disease, carcinoma (especially of the 

follicles of the intestines by -which it is attempted to be thrown off, or inducing a deposit 
in the lung, which has various pernicious tendencies (^ 474), 

[Rokitansky, Vogel, Engel, and most of the German pathologists, describe the " typhus- 
material," and believe it to be an important pathological element in most cases of typhus. 
It occurs, according to them, as a more or less firm lardaceous mass of a yellowish or 
whitish color, deposited, most frequently, in the intestinal canal, between the mucous and 
muscular coats, in Peyer's glands, and in the mesenteric glands ; less frequently in the 
spleen and lungs, and in and under the mucous membrane of the trachea, and in the 
bronchial glands. Dr. H. Bennett, in an interesting paper on the morbid appearances of 
typhus, as it occurred in Edmburgh in 1846 and 1847, published in the Edinburgh Monthly 
Journal, for 1847, found the typhous deposit in the lungs, spleen, and intestinal canal ; 
and confirms the views of the German pathologists. 

It may be either in a fluid or solid form. Engel says, the "fluid matter is a viscid 
opaque, greenish-brown material, which, when allowed to remain at rest for some time, 
deposits an abundant sediment of epithelial cells, crystals of ammonia-phosphate of mag- 
nesia, and brownish flocculent coagula, whilst the fluid itself remains of a brownish or 
reddish color, and contains a considerable quantity of albumen ; it undergoes no other 
change than that of decomposition. The solid portion of the typhous product appears in 
the solitary and Peyerian glands of the small intestines, in the follicles of the large in- 
testines, and in the mesenteric glands; it assumes the forms of these various parts in which 
it occurs, has a soft, pulpy consistence, a grayish-red color, and appears, shortly after its 
deposition, as a finely granular substance, mixed with blood-corpuscles, and seems to be 
chiefly composed of albumen.* Examined beneath the microscope, Vogel found this 
substance appearing ' as an amorphous, slightly granular mass, of a brownish-white color, 
within which a large 'quantity of small-sized cells were deposited. These cells had an 
irregular roundish form ; the majority were below l-300th of a line in diameter; a few 
measuring from l-150th l-200th of a line ; some were distinctly nucleated. By treatment 
with acetic acid, the amorphous substance became transparent, and gradually disappeared, 
upon which, very small cells (cell-nuclei?) with sharp outlines came distinctly into view, 
being unaffected by the acid. Both cells and blastema were dissolved by ammonia and 
by caustic potash. The glands of the colon contained a substance exactly similar to that 
found in the mesenteric glands, and in those of the small intestines.' "f 

Dr. Bennett says : " The minute structure of the typhous deposit varies in different situa- 
tions. In the lungs, spleen, and intestinal canal, it contains, at an early stage, a number 
of roundish or irregularly-shaped corpuscles. They are about the 100th of a millimetre 
in diameter, contain several granules, with a nucleus about the 500th of a millimetre in 
diameter. Acetic acid renders them more transparent. They are conjoined with nume- 
rous granules and molecules, which become more abundant as the process of softening 
advances. In the mesenteric glands, a higher degree of cell-formation takes place. 
Cells are formed about the 50th of a millimetre in diameter, containing from two to six, 
and sometimes even more nuclei, which become very distinct, with thick edges, on the 
addition of acetic acid, whilst the cell-wall is partially dissolved. Tlie same cells may 
occasionally be seen in the elevated typhous deposits of the intestinal glands. Sometimes, 
the only !ippf:;i ranee observable in the deposit, is that of numerous molecules and granules 
mixed with blood-corpuscles." — C] 



* Sclimiflt's Jalirbiicher, No. 7, 1845. Lond. Med. Gaz. vol. xxxvi. p. 1216. 
■}- Clymer on Fevers, p, 237. Pliil. 1846. 



PARTIAL ATROPHY. 305 

stomach), or some serious organic disease. The chief exception to this 
is diabetes, the intractable persistence of "which is involved in much 
obscurity. 

532. Partial atrophy, the reverse of partial hypertrophy (§ 528), 
commonly arises from defective supply of blood to the part. Sometimes, 
the defective supply is from the disuse of the part ; thus the eye \Yastes, 
in confirmed blindness ; muscles and whole limbs become atrophied from 
disuse, in paralysis and anchylosis; the testicle and the mamma waste 
with age, &c. Frequently, partial atrophy in an organ succeeds the 
changes induced by inflammation or other structural disease ; the matter 
effused swells some parts, compresses others of the texture, and, by pre- 
venting a due supply of blood, causes a subsequent atrophy. This is 
especially the case vfhen the products of inflammation or congestion are 
cacoplastic, as in cirrhosis of the liver, and granular disease of the kid- 
ney, in the consolidation of the lung caused by pleuro-pneumonia, &c. ; 
the deposits here produced, tend to contract and compress the vascular 
structure, and thus deprive the organ of its nourishment ; it accordingly 
shrinks in size, or, in the case of the lungs, the texture may become 
thin and emphysematous. In chronic pneumonia and phthisis, also, 
many bloodvessels in the lung become obliterated, and the texture may 
either waste or farther degenerate, according to its condition. Atrophy 
of the heart and brain have sometimes been found connected with ossi- 
fication and partial obstruction of the arteries supplying them. The 
dwindling of limbs in children, and the lameness in old persons from 
shrinking of the neck of the thigh bone, appear to depend on similar 
impediments in the vessels supplying the parts. 

[Mr. Curling has shown that atrophy may occur in that portion of 
fractured bones which is cut off from the direct supply of blood through 
the great medullary artery. It will be shown presently (§ 545), that 
fatty degeneration is very frequently present in cases of atrophy, though 
in such cases the diminution in bulk is slight or null. Atrophy of the 
muscular tissue may depend on a deficient production of motor power in 
the nervous centres. Dr. Carpenter gives an interesting example of this 
in the last (5th Am.) Edition of his Principles of Human Physiology. 
He says that he has had under his observation three males of a family 
who have "progressively become affected, between the ages of three and 
five years, with fatty degeneration of the muscles, which has proceeded 
in the most advanced case to the almost complete obliteration of their 
normal structure. This change had been considered by many eminent 
practitioners to be idiopathic, that is, to have its primary origin in the 
muscular tissue ; and the measures which had been employed to arrest it 
had been of no avail whatever. It was a strong argument, however, 
against such a view of the case, that, in the heart of the eldest son, who 
died of fever at the age of sixteen, no fatty degeneration could be disco- 
vered ; and on making inquiry into the history of the parents and their 
families, ample evidence was discovered for the belief that the disease 
was dependent upon want of functional power in the nervous centres. 
Acting on this view, it was recommended that the muscular system 
should be kept as much as possible in a state of active exercise, and that 
a weak galvanic current should be frequently transmitted through the 
20 



306 STKrCTURAL DISEASES. 

limbs from the spine. This treatment has proved so far successful that 
the progress of the disease appears to have been arrested in the most 
advanced case, whilst a decided improvement has taken place in the 
condition of a younger child, who was previously passing rapidly into 
a state resembling that of his elder brothers." — C] 

633. The treatment of general atrophy (§ 530), must be directed to 
remove or obviate the cause, where that is practicable, to supply proper 
and adequate nourishment, and to promote the healthy action of the 
digestive, assimilatory, and circulatory functions. The means of ful- 
filling these indications, where attainable, would requii-e too lengthened 
a detail to be introduced here ; it must suffice to mention the chief re- 
medies and measures to be opposed to the several pathological causes of 
atrophy. 

Atrophy, from excessive or prolonged exertion, is to be treated by a 
sufficient amount of rest and nourishment, with wine or other stimulants 
also, if exhaustion still prevails (§ 84) ; that from anxiety of mind, suffer- 
ing, or sleeplessness, by various medicinal narcotics and change of air 
and scene, as well as by measures calculated to soothe under the particu- 
lar circumstances. The effect which opiates and other narcotics some- 
times have in diminishing the urea excreted in such cases, points out 
that these remedies tend to control decay, and they may in some cases 
be aided by mineral acids and various tonics. The same remedies are 
useful in diabetes mellitus, the marasmus of which is, however, to be 
still farther checked by withdrawing all articles of food that can be 
converted into sugar — that is, all farinaceous, amylaceous, saccharine, 
and frelatinous matters (§ ^oBV I have orenerallv found the excessive 
discharge and the emaciation of diabetes to be effectually controlled by 
the full application of this rule, but never by its partial observance, as 
recommended by Dr. Prout. 

The counteraction of the circumstances which impair or prevent repa- 
ratory nutrition (§ 530), comprises the treatment of the several diseases 
and causes of disease before enumerated under the seven heads, which it 
is not necessary to recapitulate. In most of these, the use of food as 
nourishing as the stomach can digest, and of tonics, medicinal and 
hygienic, as bracing as the body can bear, mth due attention to the 
regularity of the excretions, affords the best chance of resisting or 
retarding the emaciation ; and their utility will much depend on the 
judgment with which they are applied. The utility of fat in the process 
of nutrition has been several times pointed out (§§ 66, 211, 224), and in 
addition to a fair allowance of milk, butter, and fat in food, or instead of 
them where they disagree, the cod-liver oil is a valuable remedy in 
atropliy. It is most suited to scrofulous cases, but I have experienced 
its utility in convalescence from fevers, and from prolonged and wasting 
attacks of rheumatism. 

534. As partial airoplnj often arises from defective circulation in a 
part, it may sometimes be counteracted by measures calculated to pro- 
mote the passage of blood through that part. Thus, muscles wasted by 
disuse are sometimes increased and strengthened by blisters, stimulant 
frictions, electricity, and exercise. Atrophy following inflammation or 
congestion may sometimes be advantageously opposed by the remedies 



PERVERTED NUTRITION — INDURATION AND SOFTENING. 307 

for the results of these conditions, especially iodine in combination with 
tonics, as iodide of potassium and sarza, iodide of iron, &c. In this and 
most other cases of structural disease, although treatment can do little 
to remove partial atrophy already induced, yet it may sometimes retard 
its increase by restoring a more healthy circulation throughout the body. 
[It has been ascertained by the experiments of Dr. John Ileid,^ that 
the atrophy of paralyzed muscles is due to their disuse, and that their 
nutrition is sustained when they are artificially stimulated to action. 
Mr. Paget, in the excellent lectures before quoted, observes that, when 
a person has had hemiplegia, the paralyzed limbs remain incapable of 
action long after the brain has, to all appearances, recovered its power. 
This abiding paralysis is not the consequence of any continuing disease 
of the brain, but should be ascribed to the imperfect condition of the 
muscles through inaction. So long as the state of the brain makes vo- 
luntary action impossible, the muscles are suffering atrophy ; then, when 
the brain recovers, they are not in a state to obey its impulse, they are 
degenerate ; and their inaction continuing, they degenerate more and 
more, and finally never recover their function. We ought, when muscles 
are paralyzed through disease of the nervous centres, to give them arti- 
ficial exercise ; as exciting the reflex movements — by electricity and other 
means, which will insure their nutrition, and when the nervous system 
recovers they may be in a condition to act under its impulse. It has 
been suggested^ that, in cases of hysterical paralysis, in which the con- 
dition of the nervous system suspends, for a time, its functional influ- 
ence over the muscular parts, and in which there is every reason to hope 
that this influence will, in some way or other, be restored, this treatment 
may prove especially applicable. — C] 



PERVERTED NUTRITION. 

535. Under this head are comprehended all those changes of textural 
nutrition that go beyond mere degrees of plus and minus in the natural 
molecules of the textures ; they either alter the quality of the texture, 
or form new textures, growths, or deposits, in connection with the nor- 
mal texture. These changes often comprise partial hypertrophy and 
atrophy as well ; and in so far as they do so, the observations already 
made with regard to those elementary changes may be extended to these, 
but with new additions. 



SECTION lY. 

INDURATION AND SOFTENING. 

536. "We have mentioned both induration and softening to occur as 
the results of inflammation ; softening being commonly connected with 

^ Edinbui^gli Monthly Joiirnal of Medical Science, May, 1841. 
2 British and Foreign Medico-Chirurgical Reyiew, vol. i. p. 423. 



308 STRUCTURAL DISEASES. 

the increased secretion and absorption occurring in acute inflammation 
(§ 427) ; or during the dissolving process of suppuration (§ 461) ; and 
induration being rather a sequel of the more chronic kind, which causes 
a continued overflow of the solid nutritive matter (§ 479). Both these 
changes sometimes take place independently of complete inflammation ; 
but they probably, in most cases, depend on some of its elements. 

537. Induration is constituted by an increased deposit of solid matter 
in a structure, or by compression of that structure, or by both. In some 
cases of insanity, the inner table of the skull acquires the hardness of 
ivory. In newly-born children, the skin acquires an unusual hardness 
and rigidity, rendering them " skin -bound." Glands and other soft 
compound structures sometimes become hard without inflammation. Pro- 
bably, in all these cases, there is prolonged determination of blood to the 
parts, which causes an exaggeration of the nutritive function ; but the 
matter exuded is more hyaline (§ 523), or simply granular (§§ 452, 3), 
than consisting of highly organized cell-germs or fibres ; hence the result 
is not simple hypertrophy or increased growth, but a more condensed 
and more uniform texture. A somewhat similar change is produced in 

Pi the lung by compression by liquid efi"usion or a solid tumor, especially 

when the lung itself is also inflamed, as in pleuro-pneumonia, in which 
the pressure restrains the full development of the exudation corpuscles. 
The induration of cartilage, &c., by osseous deposit is more properly 
transformation than simple induration. So induration of the liver, kid- 
neys, and other organs, generally comprises intestinal deposits, and other 
changes of structure. 

538. Softening arises from difl"erent causes in diff"erent textures. In 
some instances, the cause, being peculiar to the structure, may be called 
specific. Thus, in the bones, it proceeds from defective deposition of 
phosphate of lime, the earthy matter which gives solidity to these struc- 
tures. 

[Mr Paget believes that the disease which most English writers have 
described as Mollities Ossium is really a fatty degeneration of those 
bones. Mr. Hunter's description of a softened humerus confirms this 
opinion. He says "the component parts of the bone were totally 
altered, the structure being very diff'erent from other bones, and wholly 
composed of a new substance resembling a species of fatty tumor, and 
giving the appearance of spongy bone, deprived of its earth, and soaked 
in soft fat."^ Mr. Paget has not, from any specimen of mollities ossium 
which has come under his notice, been able to agree to the general 
notion of the nature of the disease, which refers it to the removal of 
the earthy matter of bone, and the reduction of any part of the skeleton 
to its cartilaginous basis. He has found, as the chief features of the 
structural change, softness and brittleness of the bones, with the pre- 
sence of a large quantity of adipose matter, resulting apparently from 
the conversion of the cartilaginous basis into fat. Flexibility and tena- 
city would rather be the conditions, if the calcareous matter were defi- 
cient, and the cartilaginous basis normal, llokitansky has described, 
under the name of osteomalacia, malostcon, rachitismus adultorum, an 

' Catalogue of the I'athological Museum of the College of Surgeons, vol. ii. p. 28. 



PERVERTED NUTRITION — INDURATION AND SOFTENING. 309 

affection of the bones of the trunk, occurring especially after childbirth, 
which coincides in its character with the ordinary ideas respecting mol- 
lities ossium. Similar cases of this kind have been published recently 
by Mr. Dalrymple and Dr. Bence Jones. So that, as Mr. Paget ob- 
serves, there are probably two diseases included in the name of mol- 
lities ossium — the fatty degeneration, and the simple softening of 
bones.^ — C] 

The softening of the stomach found after death is caused by the sol- 
vent action of the gastric juice. The softening of various textures, 
especially muscles, in fevers and other cachectic states, is connected with 
a defect of fibrine in the blood (§ 196); the same cause which removes this 
fibrine, and prevents its formation (§ 216), apparently dissolving or loos- 
ening the fibrinous parts of solid textures. In several cases of cachectic 
diseases in intemperate persons, commonly with degeneration of the 
liver and kidneys, I have found after death a general softening of the 
textures, which, under the microscope, exhibited an unusual predomi- 
nance of oil-globules (§ 258). In other instances, softening is a variety 
of atrophy, arising from a defective supply of blood ; so that the tex- 
ture of a part decays, and is absorbed away faster than it is repaired. 
Thus softening of the brain and heart is sometimes found connected 
with ossification and partial obstruction of the arteries supplying these 
parts. Softening of the affected muscles sometimes accompanies para- 
lysis, especially that from lead. In a few instances, partial softening, 
like atrophy, follows inflammation, and is to be ascribed to the obstruc- 
tion of vessels which that affection has produced. Thus softening of 
portions of the brain occasionally follows meningitis ; softening of the 
heart succeeds to pericarditis; softening of the stomach and intestines 
occurs after some kinds of gastro-enteritis; softening of the articular 
cartilages sometimes succeeds to their inflammation. 

In all cases of partial softening, although the chief cause is local, yet 
a non-fibrinous or aplastic condition of the blood materially assists in 
promoting this result ; and it is a serious question whether the contin- 
uance of antiphlogistic measures and abstinence does not occasionally 
promote this consequence of the changes of inflammation. Some of the 
most distinct cases of softening of the heart and brain that I have met 
with, have been those in which the patients have been long kept in a 
reduced state, for fear of return of inflammation of these organs. 

539. Induration and softening being opposites of each other, although 
sometimes preceded by similar causes, require in some degree parallel 
modes of treatment^ but in an opposite way. Induration consisting of 
condensed hypertrophy, and often arising from prolonged determination, 
may be counteracted by partial antiphlogistic measures, especially those 
tending to remove obstructions and deposits (§§ 511, 515). Thus mer- 
cury and iodine, externally and internally used, and alkaline saline 
medicines, are supposed to have some power in discussing hard swell- 
ings ; and setons, issues, or suppurating counter-irritants, which draw 
away blood and nutriment from the indurated part, may be found in 
some cases useful. But extreme antiphlogistic or reducing measures 

1 Paget's Lectures, &c. loc. cit. 



310 STRUCTURAL DISEASES. 

are not indicated (§ 218), inasmuch as induration itself implies a de- 
graded kind of the nutritive material (§ 537), and does not result from 
acute or sthenic inflammation. 

540. In cases of softening that are not specific (§ 538), the indica- 
tions of treatment are to restore a more fibrinous or plastic state of the 
blood generally, and to improve the circulation in the atrophied part. 
In fevers and cachectic states, "where the softening is general, the first 
is the chief indication, and some of the means of fulfilling it have been 
already noticed (§ 216). Besides nourishing food, and agents which im- 
prove the digestion and circulation, tonics and stimulants are often useful. 
How far the operation of mineral acids, bark, and other tonics depends 
on their astringent or bracing influence on the animal fibre, we cannot 
undertake to determine ; but after fevers, and in cachectic states, they 
do appear to improve the substance and firmness of the solids, in a way 
more direct than by merely exciting the circulation, and ameliorating 
the condition of the digestive organs. So, too, the operation of stimu- 
lants, both local and general, probably goes beyond that of accelerating 
the circulation, and determining blood to parts where it is ill supplied; 
it probably also increases the production of fibrine and cell-germs from 
the albumen of the blood, just as we see this to result from the applica- 
tion of stimulants before they cause inflammation (§§ 294, 415). The 
relief sometimes afi"orded to the symptoms of softening of the brain and 
heart, after all inflammation has ceased, by mild stimulants, tonics, and 
a moderately nourishing diet, is too little known to those who have 
always the dread of inflammation before their eyes, and who yet forget 
that a chief evil of inflammation is the injury it inflicts on function and 
structure, which injury often lasts when the inflammation is gone or is 
of trivial amount. The beneficial effect of nourishing diet and stimu- 
lant applications on soft flabby ulcers, is another illustration in favor of 
this kind of treatment in cases of internal disease, where the general 
weakness, apyrexia, pallidity, and muscular emaciation, much prepon- 
derate over the symptoms of local irritation. A chief part of the bene- 
fit arising from the use of stimulants and tonics, may be fairly traced 
to their promoting the healthy formation of blood, and an increased 
vigor of circulation; but there are some agents which seem to augment 
the plasticity of the blood, and which have no remarkable tonic powers. 
I allude to nitric acid, nitro-muriatic acid, and chlorate of potass, the 
power of which, in promoting the healing of cachectic or spreading ul- 
cers, is very remarkable; and I have obtained much advantage from the 
use of these medicines in various cachectic states following prolonged 
acute disease or habits of intemperance. It seems most probable that 
these agents are chiefly useful in supplying to the blood the oxygen 
necessary for the formation of fibrine (§ 211) or deutoxide of proteine; 
the respiration in its weakened state being inadequate to furnish a due 
amount. On a similar principle, the purest air, and such exercise or 
friction as may tend to make the respiration and circulation more effect- , 
ive, arc beneficial in these cachectic states. 

541. The treatment of the specific example of softening found in the 
bones, is not well understood. The circumstances which promote or 
impede the deposition of phosphate of lime in the bones, are not clearly 



TRANSFORMATION OF TEXTURES. 311 

known ; but measures of a tonic kind, with appropriate nourishing diet, 
have been found distinctly useful in rickets in children. The mollities 
ossium of adults, is a still more obscure and intractable affection. The 
formation of callus at the ends of fractured bone, and the completion of 
the ossific process in it, are promoted by generous diet and tonics. 



SECTION y. 

TRANSFORMATION AND DEGENERATION OF TEXTURES. 

642. When one elementary texture, as muscle, is replaced by another, 
as fibrous, it is said to be transformed. The term degeneration is also 
generally applicable to this change ; for the new texture substituted for 
the old is most commonly lower in vital properties. The chief excep- 
tions are in the case of skin being transformed into mucous membrane, 
when by anchylosis of a joint, an external surface is brought almost to 
the condition of an internal ; and the converse case of transformation of 
mucous membrane into skin, as in long prolapsed uterus. In these in- 
stances, the changes appear to arise from the physical condition in which 
the membrane is placed ; the exudation corpuscles remaining soft and 
moist, and becoming epithelium scales and mucous globules in one case, 
and drying into epidermis in the other. 

Muscle is sometimes transformed into fibrous or fibro-cellular texture, 
in some cases after inflammation of contiguous parts. Loss of substance 
in muscles, from wounds or ulcers, is generally replaced by a similar 
fibro-cellular texture, and never by new muscles. 

543. Animal textures are liable to various kinds of degeneration ; four 
of which may be particularly specified as having very distinctive physi- 
cal and chemical characters ; namely, the fibrous^ the granular^ the 
fatty^ and the osseous, or calcareous. All present the characters of 
deterioration or degradation in the scale of living textures, which the 
term degeneration is meant to imply ; and they do so in degrees corre- 
sponding with the order in which we here arrange them. In chemical 
composition, and in a fainter degree in their physical condition, they 
analogically present a successive descent from animal to vegetable and 
mineral substances. 

Fibrous degeneration chiefly affects muscular structures, especially 
when inflammation has existed long in or near them. Thus parts of the 
muscular fibres of the heart have been found converted into a dense 
fibrous tissue after endocarditis and pericarditis; those of the limbs after 
prolonged fascial rheumatism ; those of the intercostal muscles and dia- 
phragm in chronic pleurisy. Age w^orks a similar change, as displayed 
■ in the tough and sinewy condition, with wasting of size, of the muscles 
of old animals (§ 48). The fibrous tissue thus developed resembles that 
existing naturally in the tendinous and fibrous structures of the body, 
consisting of closely knit bundles of fibres, but with a scantier distribu- 
tion of nuclei, and very few bloodvessels pervading them. The fibres 
are usually also coarser, and here and there present granular irregulari- 



312 STRUCTURAL DISEASES. 

ties. They often tend in time to degenerate into the other forms of 
degraded animal substance, the granular, fatty, and osseous. In che- 
mical composition, they belong to the group of gelatigenous tissues. 
Several parenchymatous organs, the spleen, the liver, the kidneys, and 
the lungs, sometimes present a change which seems to amount to a fibrous 
degeneration, a dense filamentous tissue pervading and more or less 
superseding their natural structures ; but as in all these instances there 
is a great increase in the density of the organ, it is more correct to view 
the new fibrous material in the light of an interstitial deposit, than as a 
transformation of the proper textures. This will be considered under 
j| another head. 



tw. 



m 



544. Granular degeneration^ as commonly met with in organs, is, 
like that just noticed, the result of a cacoplastic deposit effused in the 
interstices of a texture, and exhibiting more or less of a granular com- 
position. But this same appearance is sometimes exhibited in textures 
jg under the deteriorating influence of malnutrition, chronic inflammation, 

and old age, without any augmentation of substance. We have just 
|1||; noticed that morbid fibrous tissues sometimes tend to this result. The 

' -^* same change may invade natural fibrous and elastic tissues, especially 

of the vascular system, impairing their cohesion and transparency, and 
rendering them liable to extension, laceration, and rupture ; or consti- 
tuting the first stage of the farther degeneration into fatty or calcareous 
matter. Under the microscope, the structure presents a remarkable in- 
crease of aggregated granules, with a corresponding diminution of the 
fibrous or filamentous tissue. The granules are not highly refractive, 
and there are no free oil-globules ; in this respect it differs from fatty 
degeneration ; neither is it so opaque or fragile as the true fatty athe- 
roma. It is probably a condition intermediate between fibrous and fatty 
or osseous degeneration ; and I have repeatedly found it in an artery 
which presented both these changes. Its chemical composition is un- 
certain ; but probably it is either gelatigenous or albuminous, with an 
increase of fat in the form of molecules. Cacoplastic deposits and 
recent lymph sometimes degenerate in this mode. 

[Mr. Paget has recently described^ a pathological condition of the 
heart, not previously recognized, under the name of " granular degenera- 
tion" of its muscular tissue. In this, there is neither any evident depo- 
sition of fat, nor is there that mottled appearance which indicates com- 
plete local fatty degeneration in spots or lines of the muscular tissue. 
*' The whole organ has its natural shape, size, and general external 
appearance ; but it feels soft, doughy, inelastic, unresisting, and may be 
moulded and doubled up, like a heart beginning to decompose, long after 
death ; it seems never to have been in the state of rigor mortis. These 
appearances arc more manifest when a section is made through the wall 
of the left ventricle. Then, if the wall bo only partly cut through, the 
rest of it may be very easily torn, as if with separation of fibres that 
only stick together ; and the cut surface of the wall looks, as it were, 
lobulated and granular, almost like a piece of soft conglomerate gland, 

' Lectures, &c. loc. cit. 



DEGENERATION — GRANULAR, FATTY. 313 

— an appearance which is yet more striking when observed with a simple 
lens of about half an inch focus. In color, it has not on its surface, 
much less on its section, the full ruddy brown of healthy heart, a color 
approaching that of the strong voluntary muscle ; but it is, for the most 
part, of a duller, dirtier, lighter brown, in some parts gradually blending 
with irregular marks, or blotches, of a paler fawn color." When micro- 
scopically examined, the fibres are found to show a remarkable tend- 
ency to transverse cleavage ; very minute oil particles are seen in their 
interior ; and no nuclei are found lying among them. In three cases 
in which Mr. Paget has observed this form of fatty degeneration, death 
was very sudden, and was not preceded by any symptoms indicative 
of imperfect action of the heart. It may proceed silently and gradu- 
ally, undermining the power of the entire heart, yet not rendering 
itself apparent by any functional change during the ordinary events of 
calm and quiet life ; but the individuals thus affected are wholly unable 
to resist the storm of a sickness, or the shock of an accident, or an ope- 
ration. It is very probable that many cases of sudden death, not other- 
wise accounted for, have been due to this cause; for a structural change 
of this kind may have advanced so far as to be sufiicient to destroy life, 
without being perceptible to any but a very careful and practised 
examiner. — C] 

545. Fatty degeneration was long since described by Laennec as af- 
fecting the muscles, liver, and some other structures. It is to be dis- 
tinguished from fatty accumulation, which is hypertrophy of the natural 
adipose texture, or fat-cells, and which may by its bulk press on textures, 
and cause their wasting. True fatty degeneration consists in the forma- 
tion of fat in the proper tissue of the part; thus, in fatty degeneration of 
muscles, the fibres themselves become pale in patches or spots, and under 
the microscope exhibit fatty globules or crystals within the sarcolemma ; 
and as the change increases, the color and consistence of the muscle are 
impaired, and its power proportionately weakened. This change has 
been found in the heart, and in some voluntary muscles, under circum- 
stances somewhat like those which promote the fibrous degeneration of 
the same textures ; but apparently in connection with still weaker con- 
stitutional powers, and other evidences of malnutrition. In the same 
cases, as well as in others, the arteries exhibit the atheromatous patches 
which Mr. Gulliver has proved to consist of fatty matter, which appears 
to be partly formed at the expense of the middle coat, and partly depo- 
sited in a granular and globular form under the inner lining. 

Fatty degeneration of the liver is characterized by a pale opaque ap- 
pearance of the viscus, its soft greasy consistence, its low specific gra- 
vity (sometimes floating in water), and by its greasing paper when heated 
upon it. Mr. Bowman pointed out that the liver-cells naturally contain 
a considerable proportion of oil-globules ; and he suggested that fatty 
degeneration might depend on an increase of this normal constituent, so 
great as to press on and cause the atrophy of the other tissues. It has 
been surmised that this fat is the bile, in the process of its formation by 
the secreting cells ; and that its increase, in phthisis, is due to the addi- 
tional task thrown on the liver to excrete from the system the hydrocarbon, 



314 STRUCTURAL DISEASES. 

■which the lungs m their disabled state canuot remove. If this were true, 
fatty degeneration of the liver would occur more constantly in phthisis 
and other diseases of the lungs than we find to be the case. I have met 
with it chiefly in females in whom emaciation has proceeded with great 
rapidity ; and I should rather ascribe it to the arrest of the fatty matter 
which is taken into the blood during the rapid decay of the textures, and 
conveyed to the liver as the proper excreting organ of such materials. 
It is also possible that the fatty matter which is formed in tubercle, 
during its process of maturation and softening, may be conveyed into 
the circulation, and contribute to this change in the liver. 

[Mr. Paget also dissents from the explanation of the disease generally 
admitted. He gives the following reasons against it : 1. The connec- 
tion between fatty liver and disease of the lungs is not general. In 
many who die phthisical, the liver is healthy. 2. There is no evidence 
derived from examination of the feces, that the fatty liver does secrete 
an unusual quantity of carbon and hydrogen. 3. If the carbon and 
hydrogen, supposed to be formed in extra quantity in the liver, be not 
in the feces, then the lungs would only be damaged by the excessive 
formation of those elements in the liver ; the function of the liver, in 
warm-blooded animals after birth, being chiefly preparatory to that of 
the lungs. And 4. All the conditions of the fatty liver show that it is 
an inactive organ, one which is discharging less than its ordinary func- 
tion, and the less, the more general the fatty degeneration of its cells. 
This is indicated by the analogy of all fatty degenerations, the absence 
of nuclei in the fatty cells, the absence of all appearance of the coloring 
matter of the bile in them, the large size of the liver (indicating a tardy 
or obstructed removal of its cells), the paleness and defective supply of 
blood, and the frequent coincidence of other morbid changes, such as 
would naturally hinder the proper activity of the organ. We have, too, 
a corresponding change in the kidney, presently to be noticed, with no 
excretion of fatty matter, and a diminished excretion of the proper 
materials of the urine. — C] 

But fatty transformation occurs in other organs ana tissues so com- 
monly as to show that it must arise from some chemical tendency in 
animal substances, independent of the function of any particular organ. 
Thus, we have already (§§ 223, 258, 538) noticed several instances in 
which fat-globules are found in increased numbers in various organs of 
the body, without any marked development of the common adipose tex- 
tures. This has frequently occurred in the bodies of persons who have 
been habitually intemperate, generally with more or less disease in the 
liver, with or without jaundice ; but I have met with a few such cases 
in cachectic subjects, who have not been addicted to excesses, and in 
these most commonly the urine has been albuminous, and the kidneys 
have cxliil^ited more or less of the degeneration described by Dr. Bright. 
In all these examples, all the viscera which I have examined have pre- 
sented an unusual predominance of oil-globules, with some degree of 
softening and opaque yellowish pallidity, common to ill-nourished tis- 
sues ; the liver, spleen, kidneys, and even the muscles, having a dingy 
red, or yellowish brick hue, instead of their proper colors. The in- 
crease of oil-globules in the epithelium cells of the kidney has been 



FATTY DEGENERATIOX. 315 

particularly noticed by Dr. George Johnson, who considers it to be the 
primary pathological change in Bright's disease of the kidney, corre- 
sponding Tvith fatty degeneration of the liver ; and he ascribes the 
impaired function and vrasted structure of the organ to this accumu- 
lation of fat. But although I admit the presence of numerous fat- 
globules in certain forms of degenerated kidney (indeed, I had described 
it, before Dr. Johnson made his researches), I have never seen in the 
kidney anything at all approaching to the condition of the fat liver, in 
which both cells and interstitial textures are completely glutted with oil- 
globules. 

In fact, the same increase of fat-globules vrhich, in these cases, is no- 
ticed in the kidney, is found in other textures, and is the result of mal- 
nutrition, which tends to convert other animal substances into fatty 
matter. A similar tendency is manifest in the products of inflammation 
and other deposits. Thus, the opaque exudation corpuscles found by 
Mr. Gulliver in great abundance in the lungs affected with low inflam- 
mation (especially chronic), and in gangrene, were ascertained by Dr. 
Davy to consist chiefly of oleine and margarine. The pus of old abscesses, 
mature and softened tubercle, fibrinous vegetations on the valves of the 
heart, and the softened fibrine found in bloodvessels, or on serous sur- 
faces long inflamed, also contain a very large proportion of fatty matter 
in a solid crystalline, granular, or a liquid form. The following extract, 
from Mr. Gulliver's notes to Hewson's works, bears on the same point : 
"In Dr. Benjamin Babington's observations, the specific gravity of the 
milk-like serum of the blood appeared to be so regularly reduced, as 
to lead him to believe that the oil exists at the expense of the albumen. 
There are some facts in favor of the idea that albumen may be con- 
verted into oil. The rapid disappearance of the matter of the curd of 
perfectly fresh salmon, with the subsequent more oily state of this fish, 
may be owing to a conversion of this kind, according to the conjecture 
of Sir Humphrey Davy, as I have learned from Dr. Davy. I have ob- 
served that the oil in the liver of several fishes increases after death, 
probably in connection with incipient putrefaction ; and Dr. Davy 
informs me that in the liver of the cod, after it had been kept in a 
damp place for twenty-five days, he found a small increase of oil with 
the formation of carbonic acid and ammonia at the same time." — P. 86, 
note. 

But there is no chemical fact which throws so much licrht on fattv 
degeneration as that of the formation of adipocire from animal flesh 
when kept moist without access of air. I directed attention to this 
analogy in the former edition of this work ; and Dr. Alison, in his 
recent essay on " Vital Affinities," [Trans, of Boyal Soc. of Edin- 
hiirgh. 1847,) proposes a formula by which the conversion of albumen 
and water into fat and carbonate of ammonia, may be explained. 

[Mr. Rainey, of St. Thomas's Hospital, London, has successfully 
demonstrated that, in many instances, at least, pulmonary " vesicular 
emphysema is a fatty degeneration of the delicate membrane lining the 
air-cells. This structure is very thin, almost transparent, and made up 
chiefly of an irregular interlacement of extremely delicate fibres, and 
in a healthy state is devoid of any regularly formed corpuscles. If a 



316 STRUCTUEAL DISEASES. 

thin section of emphysematous lung minutely injected, be examined by 
transmitted light, it will be found cribriform and perforated. These 
perforations are well defined, oval or circular, of various sizes, and more 
or less numerous according to the progress of the disease. In the neigh- 
borhood of these foramina, as well as in other parts not cribriform, circu- 
lar bright spots, varying in size and number, singly or in clusters, are to 
be seen, and no doubt precede the perforations. This appearance is due 
to the presence of oil in the tissue of the membrane, or on its surface. 
In some instances the oil is intimately blended with the substance of the 
membrane, and only then increases its transparency, producing the 
appearance of bright circular spots. In others again, less intimately 
blended, it exists in the form of numerous minute globules. If a small 
portion of the membrane thus affected be dried, then pressed between 
two pieces of glass and gently heated, particles of oil will be left in the 
glass, distinctly visible on examination by the microscope. If it be 
digested in sulphuric ether, all the spots disappear. It is obvious that, 
owing to a change produced from some cause or other in the pulmonary 
membrane, its materials are converted into oil. This condition impairs 
the mechanical function of the membrane, which, no longer capable of 
resisting the pressure of the contained air, breaks down. — C] 

The circumstances under which fatty degeneration takes place, much 
favor the view that I have given, of its being the result of chemical afii- 
nities, prevailing as in the examples above cited. As a general dis- 
order, or affecting many organs at once, it occurs in connection with a 
feeble circulation and low respiratory powers ; and is favored by circum- 
stances which increase the hydrocarbon of the blood, whether they be 
the habitual indulgence in alcoholic stimulants and the like, or the 
imperfect removal of biliary matter from the system. An increase of 
fat, especially of cholesterine, has been observed in the blood of aged 
persons. Fatty degeneration, affecting a particular organ (except in 
the peculiar case of the liver), is commonly a result of previous disease 
impairing the freedom of circulation through it, and often leaving a 
granular or other cacoplastic deposit in its interstices, which, not be- 
coming fully organized, nor receiving the renovating and oxidating 
influence of the circulating blood, gradually passes into a fatty condi- 
tion, the lowest in the animal scale, and, in its not possessing azote, 
approaching to the plurality of vegetable matters. The same changes 
may result more gradually from the failing circulation and respiration 
which mark advancing age (§ 48) ; and will be accelerated in any tex- 
ture or organ, the structure of which has been injured by previous 
disease, accident, or disuse. 

Under whatever circumstances the fatty transformation occurs, it is 
obviously a process of degeneration, or degradation to a very low scale 
of animal or even vegetable life (its occurrence in gangrene is a strik- 
ing illustration of this point) ; and both the vital and physical properties 
of the organs which it invades become lowered and otherwise injured. 
Thus muscles so degenerated lose much of their contractile power, and 
if subjected to distension, as in the heart, become dilated, and may be 
ru])turod. The tonic and clastic fibres of arteries also suffer in their 
spring-like properties, and may yield in pouches or become lacerated, 



CALCAREOUS DEGENERATION. 317 

or, in process of time, petrified. Glands and secreting structures lose 
much of their secernent activity, and their cells, vessels, and ducts may 
be clogged or deranged by their fatty contents, especially when these 
assume the solid form. Parenchymata and interstitial tissues suifer in 
their properties of softness and cohesion, and in the freedom of their 
circulation, and become liable to the farther changes of disintegration 
and calcareous deposition, which is the last kind of degeneration to be 
noticed. 

[Mr. Paget contends^ that what is ordinarily called " fatty degene- 
ration," is a form of atrophy, and for these reasons : 1. The frequent 
coincidence of fatty degeneration with emaciation, or diminution of size 
of the part. 2. The existence of fatty degeneration under circum- 
stances which, in other instances, give rise to simple wasting of the 
same part. 3. The frequent occurrence of fatty degeneration, with 
senile atrophy. It is generally agreed that the nucleus is the active 
agent in the changes which the cell effects. Now, in all Mr. Paget's 
observations on atrophied parts, he found the nucleus absent or imper- 
fect ; and he has so often observed this change in fatty degenerations of 
the liver, kidneys, and muscles, that he asserts the general fact that, 
when the accumulation of fat exceeds a very small amount, the nucleus 
of the cell, or other elementary structure containing it, is pale and 
indistinct ; and when the fat is abundantly collected, it disappears com- 
pletely. He does not regard the fatty matter, in such cases, in the 
light of a new deposit, but as one of the products of the spontaneous 
transformation of the tissues at the end of their proper periods of 
vigorous existence ; so that this condition represents the state of a tis- 
sue remaining unrepaired after it has fallen into the ordinary course of 
degeneration. The formation of butyric acid, during the decomposition 
of fibrine in the open air, according to Wurtz's observation, and the 
conversion into adipocire of nearly all the soft tissues of the body, 
under peculiar circumstances, are arguments in favor of this view. In 
muscular fibres, the fat-particles are frequently found arranged in the 
same manner as the proper constituents of the fibrils — sometimes in 
transverse and sometimes in longitudinal rows. From Rokitansky's 
observations, it is evident that fat is one of the products of the spon- 
taneous transformation of the higher proteine compounds. — C] 

546. Calcareous or osseous degeneration approximates the structure 
which it invades to the character of a mineral, and may be properly 
designated by the term petrifaction. The tissues most liable to the 
change are those low in the scale of organization, yet constantly moist- 
ened by the blood-liquor ; such as cartilage, fibro-cartilage, and fibrous 
tissue, and similar structures resulting from disease. This morbid ossi- 
fication has been commonly compared to the natural process of the forma- 
tion of bone ; but it resembles that process no farther than in the depo- 
sition of solid phosphate of lime in the interstices of the tissue ; and 
where that tissue approaches to bone in its structure, the result may 
resemble bone, as in the case of ossified cartilages; but in ossified fibrous 
tissue and membranes, as in arteries and the valves of the heart, the 

* Lectures, &c. loc. cit. 



318 STRUCTURAL DISEASES. 

calcareous matter forms plates and masses, which have no affinity to the 
structure of bone. In fact, the most complete specimens of petrifaction 
gradually supervene in the deposits of aplastic fibrine in lymphatic glands, 
in the lungs, on the surface of serous membranes, and on and under the 
lining membrane of arteries — Tvhich, if they escape the processes of fatty 
degeneration and softening, are ultimately converted into masses or plates 
of calculous or stony matter, in which there may be little or no animal 
substance. This process is, therefore, to be viewed as almost entirely 
chemical, consisting in the concretion and accumulation of a calcareous 
salt, phosphate of lime, in the debris of animal matter. It is uncertain 
whether this calcareous matter is the insoluble residue of a successive 
series of processes of deposition and absorption ; or the result of a chemi- 
cal attraction of degenerating albumen for the phosphate of lime in the 
adjoining fluids ; but the latter seems the more probable notion, and is 
strengthened by the fact that a similar petrifaction sometimes occurs in 
loose cartilages in joints, and in detached concretions in veins (phebo- 
lites). 

The petrifactive process is essentially a slow one ; and, as a sponta- 
neous change, occurs most in advanced age ; but, like other degenerations, 
may be induced and accelerated by inflammation, especially of a chronic 
kind. Thus the cartilages of the ribs and of the air-tubes, and many 
of the arteries, are generally more or less ossified in old people ; they 
are frequently found in the same state in earlier life, after repeated or 
prolonged attacks of inflammation in the adjoining parts. 

It is scarcely necessary to point out the various modes in which mor- 
bid ossification injures the structure and function of parts, by rendering 
them rigid, inflexible, inextensible, inelastic, and therefore brittle and 
obstructive. It is this process in particular which stifi'ens the gait, 
shortens the breath, and weakens the circulation of advanced age (§ 48), 
and renders the frame unfit to bear shocks or sudden changes, which it 
is capable of resisting when possessed of the pliancy, elasticity, and vary- 
ing powers of earlier life. So a similar change, induced by disease in a 
particular apparatus, as that of the respiration or circulation, reduces 
that apparatus to the limited capacity of decrepitude ; thus, a young or 
middle-aged person, with asthmatic breath or crippled circulation from 
such cause, is so far prematurely old, and encounters more suff'ering 
and danger in proportion as his other functions and feelings are active 
and impressible, and tempt him to trials which the straitened organs are 
unable to bear. Hence, in connection with ossified bronchial tubes, 
there may occur occasional attacks of spasmodic asthma and pulmonary 
congestion ; and, incident on ossified valves or -arteries, there may super- 
vene painful and dangerous paroxysms of angina — from all of which 
the equally, but more completely or uniformly, petrified old man may 
remain free, so long as he is kept in a state of vegetable or almost min- 
eral quiescence. These considerations suggest important points of prac- 
tical application. 



TREATMENT OF DEaENERATIONS. 319 



Treatment of Degenerations. 

547. It may readily be inferred from the preceding remarks, that, if 
any means are capable of resisting the progress of degeneration of struc- 
tures, they are those which tend to sustain the vitality of the frame, and 
to preserve the organic functions in an equally balanced activity. Hygi- 
enic influences, such as pure air, regular exercise, and friction of the 
surface, baths, warm or cold, as the system may bear them, nutritious 
and carefully proportioned food (§§ 60, 219), deserve the first mention 
among these curative or tardative measures. Of medicinal agents, those 
generally denominated tonics may be of some little utility; such as pre- 
parations of iron, bark, arsenic, and mineral acids ; but as, in most 
cachectic states, the secretions are commonly more or less defective, 
these medicines are not well borne unless combined with others which 
obviate this defect, such as alterative aperients and salines ; and the 
combination is presented in a convenient, and, through custom, in an 
attractive form, in the various chalybeate and saline mineral waters of 
the most frequented spas. These are the favorite resorts of persons of 
" worn-out constitution," who are in truth the subjects more or less of 
degenerative changes of structure, and who find in the regular routine 
of healthier habits, as well as in the virtues of the mineral waters and 
baths of these places, a degree of relief and returning strength which 
they fail to obtain under medicinal treatment at home. 

Partial degenerations we have found to be promoted by a disordered 
state of the circulation of the part, as from congestion or inflammation 
in a low form ; and the treatment must comprise the removal or counter- 
action of such local disorder, by such gentle means, chiefly topical, as 
may not compromise the constitutional powers of the subject. There 
are individual remedies which claim a notice as applicable to peculiar 
kinds of degeneration. 

548. Fibrous and granular degenerations, as they are commonly par- 
tial, and result from continued or repeated inflammations, may be in 
some measure retarded by the less weakening forms of antiphlogistic 
remedies, such as counter-irritation, local bathing, and friction with sti- 
mulant liniments, and the external and internal use of iodine in some of 
its combinations and alkalies. These means are serviceable in restoring 
power to muscles injured by rheumatic and other inflammation, which 
may end in fibrous degeneration. Mercury is generally too weakening 
as an internal remedy, but in such cases it is sometimes useful .externally. 

The more peculiar chemical nature of fat, and its special relation to 
particular organs, the lungs and the liver, suggest to us means which 
may tend to prevent its accumulation in the system, and substitution for 
the more animalized textures. The rigid exclusion of all fatty articles 
of diet, and the sparing use of saccharine matter and fermented liquors, 
and the selection of lean meats, bread, and succulent vegetables for food, 
with a fit proportion of salt and other condiments ; the promotion of free 
circulation and respiration, by regular exercise in pure air, with occa- 
sional bathing and friction to promote the healthy action of the skin ; 
and the due regulation of the bowels, aided, if necessary, by medicines 



320 STRUCTURAL DISEASES. 

which augment the secretion of bile ; such are the chief means to be 
opposed to the adipose cachexia. The tonic remedies recommended in 
degenerations in general, are also distinctly serviceable here; and I have 
known several examples of temporary benefit from them, in cases which 
ultimately proved to include fatty degeneration of the heart. In some 
instances, the nitric or nitro-muriatic acid has been found beneficial ; in 
others, ammonia ; and one is tempted to. attach some meaning to the 
peculiar composition of these agents — as opposed to that of fat — the acids 
affording oxygen, which may remove a part of the superfluous fat ; and 
both these and ammonia supplying azote, which may contribute to the 
formation of a more animalized plasma. The disposition which the 
fatty material has to assume the solid form in these degenerations, sug- 
gests an advantage likely to arise from the use of some solvent which 
may liquefy the fatty concretions ; and I know of nothing so likely to 
possess this quality as the liquid part of cod-liver oil, the utility of which, 
in removing deposits which abound in fat, will shortly come under our 
notice. 

We know little of means calculated to counteract the calcareous dege- 
neration, farther than those before recommended with the common ob- 
ject of sustaining vital energies, and preventing the nutrition of parts 
from being perverted by inflammatory or congestive disorder. Hydro- 
chloric acid exerts a remarkably solvent power on salts of lime; in some 
cases, mollities ossium has been supposed to have arisen from an exces- 
sive use of salt, but it is quite uncertain whether such a property would 
reach to the morbid deposition of phosphate of lime in textures. We 
have already given some hints on the expediency of limiting the vic- 
tims of ossification to a restricted sphere of excitement and exertion 
(§ 546). 



SECTION VI. 

DEPOSITS IN OR UPON TEXTURES. 

548. I apply the term deposits to matters which result from an over- 
flow of the nutritive material beyond what is necessary to nourish the 
textures themselves. The structural lesions, hitherto considered, are 
alterations of the textures themselves; deposits are new matters added 
to the textures. The basis of all deposits is the fibrinous matter of the 
blood; and in the products of inflammation (§§ 450-3) we have de- 
scribed its varieties in relation to its plasticity, or capability of organi- 
zation. The same division is applicable to deposits which take place 
independently of inflammation, as results of an overflow of the material 
of reparatory nutrition, and thus we have euplastic, cacoplastic, and aplas- 
tic deposits from perverted nutrition. The history already given of 
these, as they result from inflammation, will supersede the necessity of 
much detail now, and it will suffice to advert to the circumstances in 
which they arise independently of inflammation. 



DEPOSITS, EUPLASTIC — CICATRICES. 321 



Euplastic Deposits — Cicatrices. 

549. "When a living part is cut or wounded, the breach may be 
repaired by three modes : 1. By the growth of the adjoining parts, or 
w^alls, of the wound; 2. By the medium of coagulable lymph, which 
becomes organized, and forms a cicatrix, or bond of union ; and 3. By 
granulations and lymph together. The latter mode being necessarily 
attended with inflammation, is excluded from notice here ; but the other 
two, as Dr. Macartney has shown, may occur independently of obvious 
inflammation, and are more perfect without it. To these, however, a 
certain amount of determination of well-fibrinized blood, which supplies 
the plastic material, is necessary : for the process of reparation, in all its 
varieties, is always eifected from this source. 

The first of these processes occurs chiefly in very small breaches of 
the surface, as in fine punctures and incisions, and in larger wounds 
under circumstances which prevent irritation and inflammation. In 
these instances, there may be no increased redness or swelling, and no 
obvious lymph eff"used, but the sides of the wound gradually approximate 
by an increased production of the textures of the part, until the breach 
is repaired.' In this way, wounds heal spontaneously when covered with 
a hard clot of blood; or under soothing applications which exclude the 
air, and at the same time exercise a moderate and equal pressure on the 
part. '' It might be anticipated, that, as this mode of reparation bears 
so strong a resemblance to the natural formation and development of 
parts, it is the slowest mode; but this is of little account when compared 
with its great advantages in being unattended with pain, inflammation, 
and constitutional sympathy, and leaving behind it the best description 
of cicatrix."^ In the case of large burns on the trunk of children, the 
difference between the two modes of reparation will frequently be that 
of life and death, for it often happens that the patient sinks under the 
great constitutional disturbance occasioned by a large suppurating sur- 
face, although he has survived the immediate shock of the injury. (^Car- 
penter s Physiology, p. 602, Am. Ed.) 

550. The other mode of reparation is that long denominated by sur- 
geons union hy the first intention, in which the sides of a wound heal 
by the organization of coagulable lymph, or, more rarely, of a clot of 
blood, which, when complete, forms a cicatrix. The following descrip- 
tion of the process is taken from Dr. Carpenter's Human Physiology, 
3d edition, 1846, p. 600 [Am. ed.]. "This mode of union is ordinarily 

' The following observation illustrates this process : " I made a small pin-hole in a frog's 
web ; the capillaries that were diyided yielded no blood and became obstructed ; but the 
circulation continued, although sluggishly, in those adjoining, which were distant from 
the puncture the length of six or eight blood-disks. The next day, these vessels were no 
nearer ; but the circulation in them was more active, and the hole was partly filled up ; 
and on the third day it was completely so, yet no moving blood could be seen nearer to 
it. On the fifth day, the distribution of visible vessels was not altered, but the matter 
with which the hole was filled had contracted and become opaque, so that the adjoining 
vessels were drawn nearer together, and the opacity prevented my seeing whether any 
passed through the cicatrix." — Guhtonian Lectures Med. Gaz. July 30, 184:1, p. 721. 

- Dr. Macartney, Treatise en Inflammation, p. 178. 

21 



322 STRUCTURAL DISEASES. 

considered by British surgeons to be the result of an adhesive inflam- 
mation. In so regarding it, .they conceive that they are following out 
the views of Hunter; but he expressly states that wounds may heal with- 
out any pain or constitutional disturbance, the reunion proceeding ' as 
if nothing had happened ;' so that he, in effect, admits that reparation 
of this kind takes place without inflammation. It is well known that 
if a slight wound, which is thus healing, be provoked to an increased 
degree of inflammation, its progress is interrupted, and all the means 
which the surgeon employs to promote union, are such as tend to pre- 
vent the accession of this state. The doctrine that the effusion of lymph 
for the reparation of the tissues is not to be regarded as necessarily a 
result of the inflammatory process, is not so novel as its opponents have 
regarded it, since it has been maintained by many eminent observers, 
even from the earliest times. ^ The only case in which the occurrence 
of inflammation can be regarded as salutary, is that in which there is a 
deficiency of fibrine in the blood, causing a deficient organizability of 
the lymph," (or, rather, a deficiency of lymph itself.) "It has been 
seen (§ 438) that the amount of fibrine is rapidly increased by inflam- 
mation ; and the surgeon well knows that a wound Avith pale flabby 
edges, in a depressed state of the system, will not heal until some 
degree of inflammation has commenced. 

" When the liquor sanguinis, known as coagulable lymph, is effused 
between the two edges of a wound, or upon the surface of a membrane 
lining a closed sac, the following appears to be the history of its organi- 
zation. The new matter which is poured out in a fluid state, and which 
seems to have been subjected to the peculiar influence of the colorless 
corpuscles that rapidly collect in large numbers at the injured spot, 
undergoes a coagulation resembling that of the blood ; the serum, being 
set free by the concretion of the fibrine, is absorbed ; and the fibrinous 
coagulum speedily attains an almost membranous density. If examined 
w^ith a microscope at the commencement of the process of organization, 
it is seen to contain a large number of cells, which sometimes closely 
resemble the colorless corpuscles of the blood, and in other instances 
(especially w^here there has been active inflammation), present greater 
similarity to pus-corpuscles ; these cells, which are known as exudation 
corpuscles, probably originate from the granules set free from the color- 
less corpuscles of the circulating blood, and exuded with the liquor san- 
guinis. In a short time, these corpuscles present the appearance of 
regular cells disposed in layers, and adhering together by an interme- 
diate unorganized substance, bearing, in fact, a strong resemblance to 
the cells of tessellated epithelium. Some hours later, the mass exhibits 
an evidently fibrous character; and this is due to the farther elaboration 
of the plastic material by the cells just mentioned. Between these 

' Altliou^l) I iiilmit tliiitiiifhunination, in its pronounced form, is not essential to this re- 
paration, yet there seems to be a chjseapproximatio)i to this process, "When a frog's web 
is cut or pricked, tlie vessels adjoining the wound in-e immediately obstructed by coagu- 
lated blood ; but in a f<;\v seconds, those jidjoining them become enlarged, and receive an 
increased current, and it is this determination of blood towards vessels which are ob- 
structed, which causes an increased transudation of tlie plasma of the blood (^ 41'J). If 
this do not amount to inflammatioD, it differs from it only in degree. 



DEPOSITS, EUPLASTIC — CICATRICES. 323 

fibres a considerable amount of unorganized substance (§ 523) yet re- 
mains, and they may be readily separated or torn in any direction. A 
vascular rete next makes its appearance in connection with the vessels 
of the subjacent surface ; the first appearance of this network is in 
the form of transparent arborescent streaks, which push out exten- 
sions on all sides ; these encounter one another, and form a complete 
series of capillary reticulations, the distribution of which very nearly 
resembles that which has been seen in the villi of the intestines. From 
the observations of Mr. Travers, it appears that isolated globules enter 
these capillary tubes, and perform an oscillatory motion in them for 
some hours- before any series of them passes into it; so that we cannot 
regard the new channel as burroAved out by a string or file of red cor- 
puscles, pushed out by vis a tergo from the nearest capillary, as some 
have maintained.^ And he has farther established two important facts 
in the history of the reparation of tissues, which correspond with the 
observation just cited : ,1, that the liquor sanguinis, first effused, is not 
sufficiently organizable to become an entirely new and permanent tissue, 
although adequate to afford nutrition to the old, and to form a new 
tissue of temporary character; and 2, that the generation of new tissue 
is preceded by the collection of a large number of white corpuscles in a 
nearly stationary condition in the bloodvessels immediately subjacent, 
and by the appearance of a large number of similar cells in the newly 
forming tissue, the two together constituting what Mr. T. has aptly 
called the lymph-bed of organization. This process appears to be con- 
formable in all essential particulars with that which has been observed 
in the development of the toes of the larva of the waternewt and similar 
growths." « 

Under some circumstances, the fibrine of coagulable blood has been 
found to become vascular, and more or less organized. Thus clots of 
blood in the bloodvessels have been injected, and those effused in the 
brain in apoplexy have been found pervaded with vessels (Cruveilhier) ; 
but the coloring matter does not appear to assist in the process ; in fact, 
blood coagulated in or upon a wound generally comes off in a scab as 
soon as the wound is healed. In other instances, the presence of color- 
ing matter seems to retard or degrade rather than assist the plastic pro- 
cess (§ 454). 

551. The remedial measures by which the euplastic process is pro- 
moted in cases of injury, are treated of in surgical works. Their object 
is to promote such an amount of determination of blood (whether this 
be called inflammation or not), and such a plastic condition of the blood, 
as shall contribute to the effusion of a sufficient amount of healthy 
organizable lymph. Where inflammation rises too high, it causes too , 
much efi'usion of the plasma, which degenerates into aplastic pus-glob- 
ules, and it destroys the adjoining textures ; here it must be repressed 

^ There is nothing in Mr. Travers's observations which oppose the inference, which is 
drawn from numerous other facts, that the motion of the particles in these new channels is 
derived from the adjoining capillary vessels. The oscillatory movements are those of the 
pulsation of the heort, and are seen in many instances on the arterial side of obstructed 
capillaries. No current of blood, or file of red corpuscles, can pass until there is also a 
eommunication with the veins. — See note, p. 262, 



324 STRUCTURAL DISEASES. 

by antiphlogistic measures. If the inflammation is too low (§ 477), or 
the determination of blood is wanting, then the plasma will be defective 
in quantity or organizability, and the wound will not heal, or will heal 
imperfectly. Here stimulant applications may be useful. Where the 
blood is too abundant in fibrine, the plasma thrown out will be too copious 
to admit of organization, and will consequently become purulent, and 
therefore aplastic. Here, bloodletting or evacuants, and low diet for a 
time, may be serviceable. Where the blood is deficient in fibrine, the 
wound will be flabby and the discharge ichorous or sanious, from want 
of the proper plasma; here, nourishing diet, tonics, and even stimulants, 
general and local, may be useful. The efiicacy of a pure healthy 
atmosphere, which contributes to the due oxygenation of the blood, is 
sometimes very remarkable ; and the salutary effect of nitric acid, used 
both externally and internally, is perhaps to be ascribed to the same 
principle (§ 216). W^here the wound exhibits congestion more than de- 
termination of blood, and the plasma is organized into loose spongy or 
fungous masses, projecting from the wound, astringent and stimulant 
applications are beneficial. 

Cacoplastic and Ajjlastic Deposits. 

553. Under various circumstances which have been alluded to in the 
preceding remarks, wounds or ulcers may be repaired by lymph which 
is cacoplastic, or defective in organizability ; and the cicatrix resulting 
from such imperfect reparation is lower in the scale of vitality than the 
texture in which it is produced. Thus in the skin, a tough, hard, opaque 
white fibro-cellular structure, constitutes the cicatrix; the seams formed 
on the healing of scrofulous sores sometimes exhibit this character ; the 
blood not supplying a good plastic material. Or, sometimes, the cause 
of the degraded organization seems to be in the nature of the wound, or 
in a modification of the vessels of the part, or of their exudation, as in 
the scars which result from burns and scalds, and from some poisoned 
wounds. In these cases, the cicatrix is dense and thick, and tends far- 
ther to contraction, which causes a puckering of the parts, and some- 
times great distortion of the integuments. Similar deposits have been 
noticed to result from chronic and scrofulous inflammation of internal 
parts (§§ 479, 485), and from congestion (§ 311), and to constitute the 
material of dense fibro-cellular and fibro-cartilaginous formations on and 
under serous and in cellular membranes ; the indurated interstitial struc- 
ture which characterizes cirrhosis,^ and granular degeneration of the 
liver and kidneys, and old cicatrices and consolidations very commonly 
met with in the lungs. The opaque, tough thickening of the valves of 
the heart, often attended with corrugation, contraction, and rupture, and 

' Tlio term cirrliosi?! (from the obsolete Greek word mppo;, yelloiv) Avas first applied by 
Jiaenncc to tJje contractile disease of the liver; because the interstitial deposit which causes 
the contraction is often yellow from being stained with bile. The term is obviously inap- 
plicable to contractile deposits in the lung and other parts ; to which, nevertheless, the' 
name has been applied. The epithets granular or contractile deposit are respectively 
more suitable to the f(a-ms in v/hich this cacoplastic product manifests itself. 



CACOPLASTIC AND APLASTIC DEPOSITS. 325 

the similar change in the coats of arteries, appear to belong to the same 
class of deposits. 

554. The structure of these deposits deserves to be more fully inves- 
tigated. They appear to possess some organization, being composed of 
irregular cells and fibres, with more or less granular or amorphous solid 
matter to complete their substance (§ 424). They, however, exhibit 
various degrees of organization, some being vascular, and some not ; 
but they are all inferior to the structure with which they are connected, 
and to the euplastic deposits above described. Although rarely occur- 
ring in great abundance in an organ or structure, except from some 
hypereemia of that part, yet, in a small extent, cacoplastic deposits are 
to be met with in most subjects at all advanced in life, and more particu- 
larly those who have long suffered from ill health. The opaque thick- 
ening of the membranes investing the liver, spleen, lungs, heart, and 
brain, often arborescent from its accompanying the course of the blood- 
vessels — the coarser, and less regular granular appearance exhibited in 
parts of the liver and kidneys, especially at their most depending portions, 
the granules commonly adhering to the capsule of the viscus, when it is 
torn off — the partial consolidations of the lungs, particularly near their 
apex — the opaque patches in the lining membrane of the heart and arte- 
ries — are all specimens of the result of cacoplastic deposits which age 
or disease has produced ; and the more the nutrient function has been 
degraded in the individual, the more abundant will be the specimens of 
this cacoplastic deposit. But generally this deposit takes place more 
abundantly in one particular organ, in consequence of disease predis- 
posing it to suffer (§§ 31, 2). Thus, if a person, from habits of intem- 
perance, or other cause, has injured the function or structure of the liver 
or kidneys, in the lapse of time, as the nutritive function begins to fail 
from age and debility, the injured organ is the first to suffer, and be- 
comes the subject of cirrhosis, or granular degeneration ; and this may 
destroy life by arresting circulation and excretion, &c. (§§ 170, 311), 
before other organs are much affected ; hence dropsy, jaundice, albumi- 
nuria, &c. 

555. But there is another more general form of cacoplastic deposit, 
which takes place when textural nutrition is degraded still farther than 
in the preceding examples ; this is in semitransparent, miliary^ g'^ciy-, 
ayid tough yelloiv forms of tubercle. Instead of (with Laennec) classing 
tubercle under the vague term of " accidental productions," or (with 
Carswell) as a "secretion sui generis^'' I have for many years referred 
tubercle to a degraded condition of the nutritive material, from which 
old textures are renewed, and new ones formed ; and have held that it 
differs from fibrine or coagulable lymph, not in hind, but in degree, of 
vitality and capacity of organization.^ These views have received 
almost demonstrative confirmation in the microscopic researches of Mr. 
Gulliver and others, which have detected in tubercle the materials of 
lymph, but in a degenerated and confused state ; the cells being few, 

^ A somewhat similar opinion, but less definitely expressed, has been entertained by Dr. 
Alison, and formerly by M. Andral ; but these pathologists seem oiiginally to have regarded 
tubercle chiefly as the product of a modified inflammation. 



Olib STRUCTURAL DISEASES. 

irregular, slirivelled, with imperfect nuclei, and incapable of farther de- 
Telopment ; no fibres being perceptible, and the main substance being 
composed of granular or amorphous matter.^ [The microscopical ex- 
amination of tubercle presents the following characters : 1. An amor- 
phous, transparent stroma, resembling, in chemical reaction, coagulated 
fibrine. 2. Minute unorganized granules, varying in diameter from the 
800th to the 1200th part of an inch, which are not unlike the albumi- 
nous granules of the blood. They do not inyariably exhibit the same 
reaction with chemical agents, which would appear to be owing to 
the period at which they were deposited. 3. Cytoblasts, or imperfectly 
formed cells, varying in size between the 200th and 500th of a line. 
According to Lebert,^ Drs. Hughes Bennett, and Leeper.^ they never 
contain nuclei ; whilst according to Gulliver and Vogel, they are often 
nucleated. Dr. P. Blakiston says that '• it is certain that a faint ap- 
pearance of a cell-wall may sometimes be seen around these corpuscles; 
at other times, there are traces of such cells without any nuclei."^ In 
recent firm tubercle, the amorphous stroma and cytoblasts predominate, 
the latter being in clusters. In soft tubercles, they are generally farther 
apart, and less numerous, whilst the granules are greatly increased. — C] 
Every gradation may be found between euplastic and aplastic deposits : 

^ '• Coi'puscles more or less globular or oval are seen in tubercles ; but the gi'anular 
matter preponderates as the tubercular mass increases. Cells may be recognized in the 
miliary tubercles : but, as they increase in size, the well-marked and complete cells disap- 
pear. Tubercles appear to differ essentially from the plastic exudations, inasmuch as 
the cells of the latter not only grow into a higher organization, but increase in number 
towards the centre: in other words, plastic matter has an inherent power of multiplying 
and eTolring organic germs. But tubercle has no such power : for it would appear that 
its primitive cells can only retrograde and degenerate." {Gulliver's Appei^dix to Gerhers 
Anatomy, p. 87.) — '•' If a tubercle, or even the tissue of the lung neai' it, be slightly com- 
pressed between two sHps of glass with a di'op of water, it will crumble down and break 
to pieces, the fluid being at the same time quite white or milky. This white appearance 
is attributable to a great number of minute objects, the assemblage of which constitutes 
the substance of the tubercle. They consist for the most part of molecules, granules, and 
granulated corpuscles of various sizes, of aggregated granules vrithout any tunic, and of 
collapsed tunics, without any granules. These objects are mingled with a great many 
shapeless flakes and filaments, which are no doubt fragments of the membrane of the aii"- 
cells, and of the minute bloodvessels, which, when involved in a tubercle, become so 
extremely brittle, that they must necessarily form a considerable proportion of the objects 
occupying the field of the microscope. The granulated corpuscles of a tubercle are some- 
times very large (l-800th or 1-lOOOth of an inch) : and the molecules and granules, which 
are very conspicuous, may frequently be seen on the point of escaping from them. . . . 
The semitransparcnt forms of tubercle and tubercular infiltrations owe their peculiarity 
to a great relative amount of granulated vesicles (cells, Gulliver) : whereas the opaque 
white forms of tubercle are attributable to great numbers of isolated granules.'* — Mr. 
Addison's Experimental and Practical researches, ^-c, Trans. Provincial Med. and Surg. 
Association, 1843, pp. 287-8. 

These quotations supply microscopic evidence in favor of views regarding the nature of 
tubercle, which I have long held and taught, and to which I was led by an attentive 
examination of the common characters and changes of lymph, pus, and tubercle. A brief 
notice of these views maj- be found in the four editions of my little work on the Pathology 
and Diagnosis of Diseases of the Chest ; in my Lectures on Diseases of the Chest, published 
in the Mrdical Gazette, of 1837-8: and in the Library of Practical Medicine, vol. [ii. 1842; 
and Williams and Clymer on Diseases of the Respiratory Organs, p. 337, Phila.. 1844]. 
All these works were published long before any of the above microscopical examinations 
were made. 

2 Physiologic Pathologique, &c., Paris, 1845. 

3 Report on Tubercle, Dublin Quarterly .Jotirnal of Medical Science, No. YII. 

^ Practical Observations on Certain Diseases of the Chest, &c. Phil, rcprihted 1848. 



DEPOSITS, CACOPLASTIC — GRANULAR TUBERCLE. 327 



the cells and fibres, -which are the representatives of organization, dimi- 
nishing in number and completeness, and the material becoming more 
granular, amorphous, or abounding in fat-globules, in proportion as the 
deposit is degraded, until, in opaque, crude, or yellow tubercle, it is 
altogether aplastic, consisting of a mere aggregation of granules and 
fat-globules, with mere traces of the remains of cells. 

I consider that the more solid forms of tubercle are entitled to a place 
among cacoplastic deposits ; because, although destitute of vascularity, 
they seem to possess a kind of structure like that of the lower kinds of 
fibro-cartilage and granular deposit. Their affinity with granular dege- 
neration (§ 544) is shown by their commonly occurring in the same 
subjects, and by their frequently exhibiting the same tendency to con- 
traction. In a very large majority of cases of chronic granular disease 
of the kidneys or liver, there are found more or less traces of tubercle 
in the lungs, its chief seat ; and in a very few instances of chronic 
phthisis have I failed to find som.e degree of granular disease in the liver 
or kidneys. In acute phthisis and acute granular disease, local causes 
accelerate the degenerative change to a destructive extent in one organ, 
before there is time for others to become affected. 

556. Let us now trace the history of cacoplastic deposits in a few 
examples. The dense false membranes on the surface of serous mem- 
branes, may be often seen surrounded by a radiated wrinkling or pucker- 
ing of the adjoining parts, indicating that the new deposit has shrunk in 
size. A similar contraction is noticed in the deposits on and under the 
lining membrane of the heart and its valves, and causes a serious dis- 
turbance of their mechanism. The contraction of the chest, in some 
cases of pleurisy, is in part dependent on the same property of caco- 
plastic deposits. This general tendency of false membranes to contract, 
was long since pointed out by Dr. Hodgkin and Laennec ; and the fact 
has been subsequently applied by Dr. Carswell to explain the contrac- 
tion of the liver in cirrhosis, which he considers to depend on a deposit 
in the intravascular filamentous texture prolonged from the capsule of 
Glisson. I do not consider that the contractile deposit in cirrhosis is 
exclusively confined to any texture, but is exuded from the distended 
bloodvessels themselves. False membranes, which exhibit the same 
contractile property, are sometimes found on the free surface of serous 
membranes, and especially along the course of the vessels (veins as well 
as arteries) ; and on the liver and lung, depressions, from atrophy of 
the substance of the organ, are sometimes seen under these deposits. 
There can be little doubt that these deposits are a fibrinous material 
exuded from the vessels in certain pathological states (congestion, 
chronic inflammation, and malnutrition), and form a dense structure 
of low vitality, which, by its subsequent contraction, tends to constrict 
and compress the subjacent parts, and more or less to interfere with 
the passage of blood through them, and consequently with their secre- 
tion and nutrition. The same tendency is shown in the higher (less 
aplastic) forms of tuberculous disease. Miliary or granular tubercles 
in the lungs, when in considerable numbers, and not soon softening, 
cause a contraction of the lung, chiefly at the upper part, and a corre- 
sponding -collapse in the upper part of the chest. I have met with 



828 STRUCTURAL DISEASES. 

manv cases, in which a sinking in of the infraclavian region took place 
before any symptoms of softening or excavation had occurred ; indeed, 
it is a very common sign of tubercles which long remain stationary. 
The still greater amount of collapse, in the advanced stages of tuber- 
culous lesions, although partly dependent on other causes, is also in 
some degree connected with the contraction of cacoplastic deposits in 
the lungs and pleura. In the peritoneum, agglutinated tubercles often 
cause considerable contraction ; and I have seen the omentum thus 
puckered up into a knotty mass. 

The microscopic examination of cacoplastic deposits at different 
periods gives much explanation of these contractile changes. When 
recent, it consists of fibres with a great amount of granular matter, with 
and without cells, and more or less amorphous material. When ex- 
amined older, and after having contracted, it is much more tough, and is 
found to be more distinctly fibrous, much of granular and amorphous 
matter having disappeared. Old contractile adhesions and cicatrices 
are still more dense, and are found to consist almost entirely of closely 
interwoven fibres, differing from those of fibro-cartilaginous tissues 
only in being less regular and distinct. It appears, therefore, that it 
is by the partial absorption of the granular and amorphous portion of 
the deposit, and by the closer approximation of the fibres or more organ- 
ized constituent, that the condensation takes place. Hence it is that 
the structure so contracted is less liable to the farther degeneration to 
which cacoplastic deposits commonly tend. Certain it is that, of differ- 
ent portions of cacoplastic deposit in the lungs and elsewhere, those 
that are contracted remain unchanged, whilst others pass into the aplas- 
tic state of opaque and softened tubercle. This contractile process 
seems, therefore, to raise the deposit to a higher standard, in which, 
although below them, it is tolerated by the adjoining textures. But 
this very change may seriously injure the textures of organs, by con- 
tracting and compressing their vessels, and interfering with their nutri- 
tion and other functions; and in this respect it may be classed with the 
highest, or most animalized variety of degeneration, the fibrous, which 
has already been described (§ 543). This is the chief mode in which 
contractile diseases of the liver and kidneys gradually infringe on the 
circulation and secretion of these organs, and thus may eventually prove 
fatal (§§ 249, 375). The contraction which takes place near the summits 
and roots of the lunojs, in the more limited and therefore chronic forms 
of pulmonary tuberculous disease, often lays the foundation of emphy- 
sema of the lungs and habitual asthma. I have notes of a large number 
of cases illustrative of this fact; but such details belong to special patho- 
logy, and are reserved for another work. Similar contraction occur- 
ring in the deposit under mucous membranes of the alimentary and 
uri)iary passages, constitute strictures, which occasion much distress and 
serious disorder. 

557. Having adverted to the less degraded or degenerating form of 
cacoplastic deposits, we have now to notice those of a lower character, 
whicii tend to become aplastic. These include the commoner forms of 
tubercle. In the granular, miliary, gray, or drab-colored tubercles of 
serous membranes and parenchymata, we find a dense homogeneous 



DEPOSITS, CACOPLASTIC — TUBERCLE AND ITS CHANGES. 329 

solid, closely resembling some of the other cacoplastic deposits which 
have just been described. Their resemblance, and even identity, may 
often be well traced in chronic or subacute arachnitis, peritonitis, and 
pleuritis, in which portions of the affected membrane are covered with 
diffused patches of semiopaque deposit which no one would hesitate to 
call false membrane ; whilst in other parts, the same deposit occurring 
in separate granules, exhibits all the characters of granular or miliary 
tubercle. But how -comes it (it may be asked) to assume the gran- 
ular form? In answer to this question, I may refer to the observations 
made on the products of inflammation (§ 449), where it was pointed out, 
that the effusion of lymph on an inflamed membrane is at first granular, 
and would continue to be so, if it were not drawn or spread into threads 
or films by the friction or pressure of the surfaces where it is poured 
out ; and several examples were cited, in which, from the absence of 
such friction or pressure, the granular appearance is preserved even in 
acute inflammation. In scrofulous and chronic inflammation, in which 
the matter effused is from the first less ductile and more consistent, the 
granular condition more generally prevails and remains even in spite 
of pressure and friction ; and it is generally admitted that the pro- 
duct of chronic inflammation of the peritoneum and arachnoid is al- 
ways more or less granular. Even in acute inflammation of tubercu- 
lous subjects, recent lymph is commonly studded with opaque granules, 
which subsequently would assume the character of tubercles. 

But tubercles do not always result from inflammation. In many 
cases, they are found disseminated in so many textures, after few or no 
symptoms of inflammation, that it is impossible to regard them other- 
wise than as the result of modified textural nutrition. The cell-germs 
by which the material of textures is renewed, are imperfect at particular 
points; agranular or amorphous matter is deposited from the plasma, 
and concretes without fibres or regular cells being developed ; at this 
point a granulation appears, and gradually hardens. Where a granule 
has once been formed, it becomes a nucleus for the concretion of more ; 
a new habit or mode of nourishment is established at the spot ; or, to 
speak less figuratively, cacoplastic matter (if present in the blood plasma) 
concretes around it by a process similar to that by which fat attracts fat, 
or bone osseous matter ; perhaps the process is not wholly unlike that 
of crystallization. But however it happens, the result is, that the granu- 
lar tubercle grows, and may attain the size of a millet-seed, hempseed, 
or even a small cherry-stone ; or, being subjected to pressure, may 
slightly spread or flatten into various shapes. 

The microscopic character of these miliary or granular tubercles is 
the complete predominance of minute and often irregular granules, and 
the comparative absence of fibres and cells, of which mere traces are 
seen, at least in the older specimens. The granules are aggregated 
together by an amorphous material, the solidity of which gives hardness 
and some translucency to the mass ; for acetic acid or alkalies, which 
dissolve this cement, loosen the granules and render them distinct. 
The chemical nature of granular tubercle is albuminous, with some 
gelatine and a little fat, the latter in very minute proportion, and occu- 
pying the centre of some granules ; and the gelatine being probably the 



330 STRUCTURAL DISEASES. 

amorphous cement just noticed. In all these characters, we find a close 
analogy to the granular degeneration of textures (§ 544), and of which 
doubtless these deposits are a kind of exaggeration. 

558. Tubercles rarely grow much or last long without exhibiting 
another change in their appearance. They lose their semitransparency. 
and become of an opaque or dead pale yellow hue, like the color of raw 
potato or parsnip. This is the transformation to crude yellow tubercle 
first described by Laennec. This change is the result of a farther de- 
gradation or degeneration of the deposit. The few fibres and cells which 
are to be detected in gray tubercle become indistinct, the interstitial 
hyaline or amorphous solid diminishes, and oil-globules appear in its 
stead, and the mass becomes less coherent and more granular, and 
therefore quite aplastic. Generally, the change begins in the centre of 
the mass ; apparently because, being devoid of vessels, the centre is 
farther removed from the vivifying influence of the blood. In a similar 
manner, the cornea and other nonvascular textures become opaque from 
deficient supply of sustaining nutriment in the plasma, and may wholly 
lose their organization (§ 269). A parallel degradation is observed in 
the degeneration of fibrous and cellular tissues into granular matter, 
recently pointed out as the result of malnutrition (§ 544). But not 
only will deficient supply of plasma promote the transformation of 
tubercle from gray to. opaque ; but an undue flow or accumulation of 
blood, as by congestion or inflammation in the neighborhood, will also 
accelerate this change, just as they hasten the disintegration of lymph 
and of compressed textures, the plastic into the aplastic, by the increased 
warmth and afilux of fluids exalting chemical affinities in a material 
which has no vital power of resistance by which living tissues maintain 
their integrity. 

559. But tubercle is frequently deposited at first in this yellow, opaque 
state, this circumstance being a mark of the still more degraded condi- 
tion of the nutritive function ; and the more extensive forms of tuber- 
culous disease commonly abound in this aplastic matter. Thus in rapid 
phthisis, whether resulting from acute inflammation in a scrofulous 
subject, or from the excessive prevalence of a scrofulous diathesis (caco- 
plastic matter in the blood), yellow tubercle commonly forms a large 
portion of the deposit ; and it is in these cases that its resemblance to, 
and connection with, coagulable lymph, may be best seen.-^ Yellow 
tulx^rcle is rarely so hard or so tough as the gray or semitransparent 
kind ; and in the cases of rapid deposit just mentioned, it is often much 
softer and more friable. Now, this is the commencement of a change 
to which the lowest forms of tubercle tend — that of maturation and 
softening into a cheesy substance. The conversion of the gray into 
opafjue tubercle, and the farther softening of this, seem to be the con- 
verse of tlic contractile process to which the higher class of cacoplastic 
deposit tend ; in that (tlic contractile process) the deposit becomes more 
dense and organized ; in this (opaque change and softening) the deposit 

' The affinity between lymph and tubercle was rccofrnized by older writers ; and after 
it had bccM kei>t out of view by the too exclusive opinions of Bayle and Laennec, it was 
again pointed out by Dr. Alison. — Trans, of Medico- Chirurg. Soc. of Edin. vols. i. and iii. 



DEPOSITS, CACOPLASTIC — TUBERCLE AND ITS CHANGES. 331 

becomes less dense, and loses the little trace of structure which it pos- 
sessed ; it degenerates into an amorphous, granular mass ; and being 
lifeless, it is no longer nourished ; but its granules lose their cohesion, 
and become disintegrated by the chemical action of the adjoining fluids.-^ 
Mr. Gulliver and others have observed a remarkable increase of fat- 
globules in softened tubercle. In fact, from the time that tubercle 
assumes the opaque form, these oil-globules appear to increase ; until it 
is either softened and eliminated, or undergoes the petrifactive change 
to be described hereafter. 

The formation of fatty particles in old pus (§ 460), in atheroma of 
arteries, and in chronic inflammatory deposits and gangrene of the 
lungs, seems to show that fat is sometimes a debris of animal matter, 
as in the conversion of flesh into adipocire (§ 543). The lenticular cor- 
puscles concentrically striated, supposed by Gruby to be characteristic 
of softened tubercle, Mr. Gulliver has found, in various t:extures, uncon- 
nected with tubercle or any other disease. The detection, by Dr. Davy, 
of oleine and margarine in opaque exudation corpuscles in the lungs 
(§ 543), and the observation, by myself and others, of numerous fat- 
globules in deposits in the kidneys, spleen, and vegetations on the valves 
of the heart — show a tendency to the production of fat in all degene- 
rated plasmata. In many instances, the fatty matter appears in a solid 
form, either crystallized or in granules, rather than as distinct oil- 
globules ; and this fact suggests that a change in kind, as well as an 
excess in quantity of fat in the deposits, has occurred, and probably 
prevents its absorption. These facts, which have before been noticed 
under the head of fatty degeneration (§ 545), prove that morbid deposits 
are amenable to the law of the fatty or hydrocarbonaceous transforma- 
tion, in common w^ith natural structures ; and they are more liable to 
this sinking in the scale of organic matters, in consequence of their low 
vitality, and from their extravascular position placing them beyond the 
reach of the decarbonizing influence of the circulating blood. As the 
change seems to be in a great measure spontaneous, and promoted by 
moderate moisture, it increases with the age of the tubercle, within 
certain limits, beyond which the mineral transformation, petrifaction 
(also chemical), ensues. But the softening, if early, depends on a de- 
composition which is more destructive, and this, by generating matter 
ofl'ensive to the adjoining textures, and to the whole frame, may cause 
local and constitutional irritation, so strongly marked during the ex- 
tensive and rapid softening of tuberculous deposits. 

[Rokitansky thus describes the softening of tubercle: "After the 

' Dr. Elliotson, I think, first suggested that the softening of tubercles is due to a spon- 
taneous chemical change. I also consider the change to be chemical ; but to be much 
promoted by the action of fluids from adjoining parts. So long as tubercles are kept free 
from superfluous moisture, they manifest little disposition to change ; but an affiux of 
fluids around them hastens their maturation and softening. This efl"ect may be rudely 
illustrated by the action of water or serum on coagulated albumen. When nearly dry, it 
is tough and semitransparent ; but when well moistened, it becomes opaque, soft, and 
friable. The softening and disintegration of clots of fibrine by warmth and moisture give 
another illustration of the same change. [Lebert believes that the softening of tubercle 
depends upon the liquefaction of the transparent hyaline mass, in which the granular 
matter is imbedded.— P/iysfo%?e Pathologique, ^c, Paris, 1845. — C] 



332 



STRUCTURAL DISEASES. 



tubercle has existed for some time in the state of crudity, it becomes, 
as it were, loosened in its textures, and usually increases in volume; it 
breaks up on slight pressure, and becomes more moist; then changes 
into a yellowish, dissolving, caseine-like, fatty and viscid matter, and 
finally breaks up into a thin, whey-like, acid fluid, in which flocks and 
shreds — the remains of the imperfectly disintegrated tubercle — are ob- 
served sw^imming. This is tubercular pus. 

"The softening consists in the solution and disintegration of the solid 
groundwork of the tubercle, into a fluid containing an abundance of the 
minutest molecules. This change is followed by a separation and isola- 
tion of the above-named histological elements of tubercle, which under- 
go more or less marked alterations by their immersion in the fluid; the 
cells become distended, corroded, and are finally dissolved ; the nuclei 
shrivel, and assume irregular forms, becoming angular and indented. 
Finally, in softened tubercle we meet with free fat. 

" The dissolved tubercle consists — 

''«. Of a fluid with minute molecules. 

"6. Of altered nuclei and cells isolated in the manner we have de- 
scribed. 

"c. Of free fat in the form of elementary granules, and distinct glob- 
ules of a larger size. 

" 2. The other metamorphosis of this form of tubercle is cretefaction. 
It occurs as a secondary change, never attacking tubercle in its ori- 
ginal form, but confining itself to the dissolving or dissolved tubercular 
blastema. 

"In softening or softened tubercle, the calcareous salts and fat occur 
in the form of free, distinct, or aggregated elementary molecules, or in 
granular cells ; the fat also not unfrequently occurs in the form of large 
drops or of crystals of cholesterine. In this process, the softened tuber- 
cular mass gradually thickens into a moist, fatty, viscid kind of plaster, 
and, finally, diminishing in volume, is converted into a mortar-like con- 
cretion." — [Handhuch der patJiologisclien Anatomie, p. 398, from Bri- 
tish and Foreign Ifedico- Clm-urgical Review^ vol. i. p. 173.) — C] 

560. But in these different changes in tuberculous matter, as well as 
in the original deposition of this matter, the adjacent living parts have 
a considerable share. A miliary tubercle, from its first formation, may 
become a cause of irritation and obstruction to the contiguous textures. 
The amount of this irritation and obstruction will depend on the natural 
or present vascularity and excitability of the part, its function, and 
the situation and size of the tuberculous deposit. Thus, in vascular 
textures, especially parenchymata, there is more tendency to mischief 
and change than in serous mem])rancs. Where the irritation is very 
sliglit, it may merely cause so much determination of blood as to promote 
the growth of the gray tubercle. Where it is more, it may cause the 
conversion of gray into yellow tubercle, its farther increase in this form, 
and its softening. If the irritation be still greater, inflammation is ex- 
cited around the tubercle ; and its marks arc often seen after death in 
the areolar of vascular redness; and the products of this inflammation 
(pus, lyinpli, mucus, scrum, &c.) may also hasten the softening of the 
tubercle, their mixture together, and their evacuation by ulceration into 



DEPOSITS, CACOPLASTIC AND APLASTIC — TUBERCLE. 333 



adjoining open surfaces. Or, the product of inflammation being more 
solid and plastic, consolidations, or false membranes, are formed around 
the tubercle, and its irritating influence may be thus circumscribed. 
Thus, although we have just mentioned that the opacity, maturation, and 
softening of tubercle depend essentially on a farther degeneration and 
loss of structure, yet these changes are much promoted by the afflux of 
blood to the neighboring parts. 

661. In the absence of any of the circumstances just mentioned, 
which tend to promote the increase or farther change of tubercle, we 
find that it may remain harmless for months, and even for years ; but 
then it often exhibits farther transformations which may be considered 
spontaneous or chemical. This remark does not apply to the change 
of the less cacoplastic deposits by contraction, which has been already 
noticed as an elevation of the deposit to the condition of a fibrous tissue 
nourished and preserved as a living part. In the lungs, the consolida- 
tions may remain long without any contraction, but they become deeply 
blackened by an accumulation of the peculiar black matter of the lung. 
Yellow and softened tubercle, if not evacuated, in time becomes replaced 
by a plastery, or putty-like matter, composed chiefly of phosphate of 
lime and often containing solid concretions, consisting entirely of that 
earthy matter. — [These cretaceous or puttaceous remains, are general- 
ly found encysted. — C] This petrifactive change reminds us of what 
takes place in the cacoplastic deposits in the coats of arteries and on 
serous membranes (§§ 544, 553), constituting what is erroneously called 
ossification; and this completes the fourth and last parallel with the 
degenerations which kindred textures undergo from the influence of age 
or disease; the osseous or mineral transformation. The calcareous con- 
version of tubercle can be explained only on the supposition that the 
organic matter is absorbed, and the earthy salt is deposited in its place. 
This is exactly like w^hat takes place in true petrifaction of organized 
bodies, the silica or calcareous substance being substituted, molecule for 
molecule; so that, when all is converted into stone, the shape of the 
organized body is retained. And we farther learn from this that the 
animal matter of tubercles may be absorbed. The occasional absorp- 
tion of tuberculous matter is farther proved by its accumulation in the 
bronchial and mesenteric glands, which sometimes contain it when the 
lungs and the intestines present little more than traces of it, such as 
cicatrices, with some cretaceous matter in them. In the bronchial 
glands, too, the tubercle very commonly exhibits the petrifactive change, 
and the concretions so commonly found in these glands may generally 
be ascribed to this cause. 

562. The circumstances which degrade the material of nutrition, and 
lead to the deposition of cacoplastic and aplastic matter, may be either 
local or general. Of the local causes, congestion, and the lowest and 
more chronic forms of inflammation have been mentioned as capable of 
determining cacoplastic deposits ; but even in these cases it is probable 
that the general cause also more or less operates — that is, a degraded 
state of the plasma of the blood. Congestions and chronic inflamma- 
tions certainly cause cacoplastic effusions ; but, then, such congestions 
and chronic inflammations do not easily occur in healthy subjects ; and 



334 



STRUCTURAL DISEASES. 



the want of health may imply that the plasma of the blood is bad in 
addition to the local cause. But practically, it is of great importance 
to keep in view the local as well as the general cause, for the former is 
often more tractable than the other, and it is by guarding against it that 
slighter degrees of the general cause (diseased plasma) may be pre- 
vented from doing mischief. But the general cause, when present in 
great degree, leads to cacoplastic and aplastic deposits, as modifications 
of ordinary textural nutrition, independently of inflammation or even 
congestion. This general cause thus prevailing, constitutes the chief 
element of the scrofulous diathesis, or tuberculous cachexia; and we have 
before mentioned that a defect of the red particles and an excess of fibrine 
in the blood constitute its most remarkable feature (§§ 185, 211). In 
this condition of the blood there is an increased disposition to deposit, 
and often an abundance of the fibrinous or nutritive material, but an 
imperfect vitality or organizability of this material, so that when depo- 
sited, instead of being assimilated to the textures, it forms the degene- 
rated structures or mere granular or amorphous deposits, which we have 
been describing. But with this condition of the blood, these deposits 
must be greatly promoted by all varieties of hypersemia, and prevail most 
in organs which receive the largest amount of blood. Hence, the pecu- 
liarly pernicious effect of inflammation of internal organs, especially the 
lungs, in scrofulous subjects. Even acute inflammation may be unequal 
to raise the nutritive material to a plastic standard at which it may be 
organized or absorbed, or to mature it to the process of complete suppu- 
ration by which it may be speedily excreted ; but the matter thrown out 
is cacoplastic or curdy lymph, remarkable for its opacity and want of 
cohesion, or a caseous kind of pus, inorganizable, inert, irremovable by 
absorption, and permanently obstructing or compressing the structures in 
which it accumulates, until it gradually excites an irregular destructive 
suppuration or ulceration, forming vomica, or imperfect abscesses, per- 
vading the structures, and without walls capable of healing; whilst under 
the depressing and irritating influence of the morbid matter decaying 
and becoming decomposed, the body wastes with hectic fever, night- 
sweats, and colliquative diarrhoea. So likewise fevers, by causing con- 
gestions in organs, lead to the production of a crop of these deposits, 
from which tuberculous disease takes its origin. 

[No point of pathology has been the subject of more violent dispu- 
tation than the question, whether or not tubercle is the result of an 
inflammatory action. Lacnncc opposed the inflammatory theory. Cars- 
well has advocated warmly and ingeniously the same view. Dr. Baron, 
of (Gloucester, thought that tubercles were not the product of any species 
of inflammation. Broussais was the ardent advocate of the inflammatory 
origin of tubercle. Andral thinks that, where predisposition exists, 
any slight local congestion of blood will give occasion to its production. 
Dr. Alison, of Edinburgh, is probably the most elaborate supporter of 
this doctrine, from his own observations, and from the experiments of 
others. Hughes Bennett, Evans, Bl;ikiston, and others, maintain the 
positive side at the present time ; whilst Nicollucci, Lebert, Gellerstcdt, 
and Rainey, oppose it. Tlie true state of the question is, to our mind, 
so justly stated by Dr. Deeper, that we give it in his own words: " For 



DEPOSITS, CACOPLASTIC AND APLASTIC — TUBERCLE. 335 

ourselves," he observes, " we have long thought that authors have been 
hunting after a shadow, in endeavoring to settle the point in question. 
Believing, as we do, that tubercular matter exists in the blood of the 
scrofulous, in the form of a tubercular plasma, we are of opinion that 
it may be exuded in that condition of the capillaries in which, under 
other circumstances, fibrine would be effused. If the latter state be 
called inflammation, and it is only an excited state of nutrition — then, 
in the case of tubercular effusiT)n, the inflammation is a peculiar and 
anormal one, and the product is also anormal."^ Dr. H. Bennett holds 
nearly the same language. — C] 

563. The lungs and bronchial glands are by far the most common 
seat of tubercles ; when found elsewhere, tubercles commonly abound 
more, and are more advanced in these parts. The situation of the pre- 
valence of tuberculous disease varies also with the age of the subject. 
Thus, M. Papavoine found yellow tubercle in children to occur especially 
in the cervical and mesenteric glands ; next, in the spleen, pleura, liver, 
and small intestines ; less frequently in the large intestines and perito- 
neum ; and more rarely in other parts. In 350 consumptive (chiefly 
adult) cases examined by M. Louis, tubercles were found in the small 
intestines in one-third of the whole ; in the mesenteric glands, in one- 
fourth ; in the large intestines, in a ninth ; in the cervical glands, in a 
tenth; in the lumbar glands, in a twelfth ; in the spleen, in a fourteenth 
of all the cases ; and in other parts, in smaller proportions. [In 100 
young subjects, Lombard found the bronchial glands an"ectedin 87, the 
lungs in 73, the mesenteric glands in 31, and the spleen in 25. In 
100 adults, the lungs not included, he found the intestines afi'ected in 
26, the mesenteric glands in 19, the bronchial glands in 9, and the 
spleen in 6. The relative frequency of tuberculization of the bronchial 
glands in the child and adult, is as 87 to 9, or 9f times more frequent 
in the former. Of three hundred and twelve tuberculous children, Rilliet 
and Barthez found the lungs free from tubercles in one-sixth only. Ac- 
cording to MM. Rilliet and Barthez, we find tubercular matter in children 
more frequently in the lung than in any other organ ; next, the bronchial 
glands ; afterwards, but at some distance, the mesenteric glands and 
small intestines. After these organs, the pleura and spleen are most 
liable ; and then the peritoneum, the liver, the larg'e intestine, the me- 
ninges, the kidneys, the heart, stomach, and pericardium. The same order 
exists with regard to the amount of tuberculization; those organs in 
which we most frequently find tuberculous matter, are those, in general, 
in which it occurs most abundantly.^ — C] 

The greater liability of the lungs to tuberculous deposits, has been 
lately ascribed by Dr. Campbell and others to the finer size of their 
capillary vessels, which causes them to act as filters to the blood, arrest- 
ing the tuberculous matter, which is supposed to become solid in the 
blood itself. But this view is untenable for several reasons: 1. If the 
fine size of capillaries Avere the chief cause of the deposit, it should take 

' Report on the Pathology of Tubercle. — Dublin Quarterly Journal of Medical Science. 
No. VI. 

2 Williams and Clymer on Diseases of the Respiratory Organs, p. 333. 



336 



STRUCTURAL DISEASES, 



place abundantly in muscle, the capillaries of which are even finer than 
those of the lungs. 2. If the cause of the first deposit were a solid 
matter obstructing a vessel, the appearance of vascular distension and 
obstruction would be obvious in the earliest formation of tubercles, and 
the deposit would exhibit somewhat of a capilliform shape, which is not 
the case. 3. The deposit has been distinctly traced by Messrs. Gulliver 
and Addison to be extravascular, sometimes on the surface of the air- 
cells, and sometimes in or under the ftiembrane composing them. I 
think it highly probable that tuberculous matter may form within the 
bloodvessels themselves ; and I have repeatedly found something pre- 
senting all the externfil characters of yellow tubercle in the bloodvessels 
of tuberculous lungs. In fact, wherever fibrine may coagulate, there 
its degraded form, tubercle, may occur ; and I cannot but refer to the 
case of opaque softening of clots of fibrine in coagula in the heart and 
great bloodvessels as bearing on this point. Formerly, this softened 
fibrine was mistaken for pus : Mr. Gulliver pointed, out this error by 
showing that it had no pus-globules. But its aspect and microscopic 
composition difi'er in no essential particular from those of soft tubercle, 
and the views which I have given would identify them in nature. This 
leads me to infer that the fibrine of blood stagnant within vessels, or 
extravasated from them, in tuberculous subjects, may sometimes change 
into aplastic tubercle. But the reasons before stated make it obvious 
that the early forms of tubercle are extravascular deposits, resulting 
from modifications of the ordinary nutritive secretion. 

I believe that several circumstances contribute to render the lungs 
especially liable to tuberculous deposit. 1. Their great vascularity and 
the large quantity of blood that passes through them, which makes them 
largely partake of any disorder in the condition of this fluid. 2. Their 
being a chief seat of the formation of fibrine, that principle being more 
abundant in arterial than in venous blood (§ 194). 3. The softness 
and yielding nature of their texture, which permits eff'usion to take place 
more readily than denser textures do. 4. Their exposure to external 
causes of disease, whether by cold and irritations directly entering by 
the air-tubes, or by circumstances operating through the medium of the 
circulation. In hot climates, cacoplastic diseases affect the liver and 
other abdominal viscera more than the lungs ; the same persons there 
sufiering from chronic liver disease and dysentery, who, in a cold climate, 
would fall victims to phthisis. 

564. As we have found (§ 5G2) that the cacoplastic condition of the 
blood of tuberculous or scrofulous subjects comprises a diminution of 
the red particles and a preponderance of fibrine, so we can state that 
the causes which develop tliis condition, and therefore induce tubercu- 
lous disease, nvo such as intclligi})ly induce one or both of these changes. 
Insufficient food, want of pure dry air, of warmth, and of light, long- 
continued mental depression, aggravated and prolonged disease of the 
digestive' organs, insufficient excretion (§ 249), and the injurious influ- 
ence of fevers and other serious diseases, are acknowledged causes of 
tuberculous disease, and may be considered to operate in both ways. 
Excessive evacuations of blood, or of the more animalizcd secretions, 
and severe courses of mercury, also predispose to phthisis, and perhaps 



DEPOSITS — TUBERCLE — CAUSES — TREATMENT. 337 

act chiefly by reducing the red particles of the blood, and the quality of 
the plasma. The cessation of growth, the termination of pregnancy, 
the stoppage of habitual discharges, especially purulent, and the ampu- 
tation of a limb, all of which circumstances are known to favor the de- 
velopment of tubercle, may be supposed to operate chiefly by increasing 
the proportion of fibrine in the blood, when there is not a sufliciency of 
red particles, and of vital power, which is represented by them (§ 183) 
to give to this fibrine a due amount of elaboration and capacity for the 
properties of life. 

■ 565. The treatment of cacoplastic and aplastic deposits, and of the 
conditions which lead to them, involves a vast number of details, accord- 
ing to their kind, situation, extent, and other circumstances in which 
they occur. It is not consistent with the limits of this work to enter 
into these details ; but it is hoped that a rational view of the principles 
on which these deposits are to be prevented and treated may be deduced 
from the foregoing account. This view will comprehend those measures 
which have the best sanction of experience. 

The elements of cacoplastic diseases chiefly to be kept in view in the 
treatment are : 1, tJie dkordered condition of the blood, and its causes ; 
2, the d.isordered distribution of the blood, and its causes ; and 3, the 
presence of the deposit, and its effects and changes. The second element 
comprehends the varieties of local hyperemia, which we have found to 
be so much concerned in producing the higher kinds of cacoplastic de- 
posit (§ 553), and in promoting the formation and changes of those of a 
lower character (§ 560). Hence, the remedies against inflammation, 
determination of blood, and congestion, are frequently more or less 
needed in the prevention and treatment of cacoplastic and aplastic 
deposits. But, except as preventives, the -utility of this class of reme- 
dies is generally limited to those of a topical kind, such as local blood- 
letting, counter-irritants, revulsives, derivants, and alteratives (§ 174). 
No remedies of this class have appeared to be so generally useful as 
counter-irritants of the milder class, rubefacients, extensively and regu- 
larly applied by friction over a large surface of the body. These operate 
not only as revulsives, which diminish the congestions and irritations of 
internal organs ; but also by increasing a free circulation on the surface, 
which promotes the purification of the blood by perspiratory excretion, 
and aids the lungs in the process of arterialization. 

oQQ. The more constant and important element to be considered, in 
the treatment of cacoplastic and aplastic diseases, is the first named — 
the diseased condition of the blood; and this more demands attention, 
the more general and the more degraded are the deposits. The first 
point to be attempted is the removal or counteraction of the several 
causes before enumerated (§ 564), as contributing to induce the diseased 
condition of the blood. Thus a sufficient supply of food of a nutritive 
and digestible quality, comprising especially the highest order of pro- 
teinaceous articles (§ 60) — free access to a pure dry air and light, while 
the warmth of the body, particularly of the surface and extremities, is 
carefully secured by adequate clothing, and regular exercise proportioned 
to the strength — the removal or counteraction (so far as possible) of dis- 
22 



oo8 STRUCTUKAL DISEASES. 

eases impairing digestion and excretion, and of depressing mental or 
bodily influences — are among the first objects to be aimed at in treating 
cacoplastic diseases. Where excessive losses of blood or other evacua- 
tions have contributed to lower the plastic process of nutrition, a gene- 
rous animal diet, and tonics, especially those containing iron, are espe- 
cially indicated. Where the altered condition of the blood can be traced 
to an excess of ill-developed fibrine accumulating after the cessation of 
growth, the termination of pregnancy, the amputation of a limb, or the 
sudden stoppage of an habitual purulent or other discharge — means to 
eliminate the superfluous matter from the blood, either by increasing 
the natural secretions, or by establishing an artificial drain by blisters, 
setons, issues, suppurating counter-irritants, &c., are distinctly indicated; 
whilst tonic and invigorating measures may be also useful to raise the 
plasticity of the blood to a higher standard. Some of the remedies to 
be mentioned in relation to the third indication, are sometimes useful in 
promoting this object also, such as cod-liver oil, nitric acid, and com- 
binations of iodine, which have direct influence on the nutritive functions. 
The foregoing measures may be considered rather as preventive than 
curative ; but in so far as they may succeed in arresting the augmenta- 
tion of deposits already formed, and in improving the nutritive function 
in general, they will favor the limitation of the deposits, and their gra- 
dual absorption or quiescence in contraction (556) or calcareous trans- 
formation (§ 561). 

567. The third object to be regarded in the treatment, is the deposit 
that is already formed, with the view to promote its removal or quies- 
cence. This end is the more difiicult of attainment, and the class of 
diseases therefore more intractable, because, being for the most part 
non-vascular, the deposits are little under the influence of absorption 
and of the vascular currents, by which it and other changes are efi'ected. 
Unlike with the euplastic products of inflammation, and, in some in- 
stances, unlike with a simply overgrown texture or organ, the changes of 
absorption are slow to reach deposits which are very solid and remote from 
vessels; and it is doubtful whether any remedy that we can use can surely 
promote their removal, unless, perhaps, by the simultaneous destruction 
of the texture which contains the deposits. The constitutional influence 
of mercury has seemed to me to hasten the softening and evacuation of 
pulmonary tubercles ; but this is by such a work of destruction, and its 
influence on the blood has been already mentioned to be injurious. Drs. 
Graves and Stokes, and others, have, however, recommended mercury 
in the earliest stage of tuberculous disease. My own experience would 
lead me to avoid the specific influence of mercury, in all cases of mere 
tubercle ; but I have given it with advantage in cases of subacute and 
chronic inflammation simulating tuberculous disease, and even where 
tubercle probably existed in a limited extent. I am less doubtful of the 
utility of mercury (chiefly by way of inunction), in incipient cacoplastic 
or tuberculous deposits on serous membranes, particularly the peritoneum, 
which is a general result of chronic inflammation. I have successfully 
treated several cases, in which the signs and symptoms left me in no 
doubt as to the existence of tuberculous peritonitis, by ointment of iodide 
of mercury to the abdomen (covering the surface with India-rubber cloth), 



DEPOSITS, CACOPLASTIC AND APLASTIC — TREATMENT. 339 

together witli iodide of potassium internally. Whether mercury is of 
any use in granular disease of the liver and kidney, is a subject of doubt. 
Alkalies and their carbonates, and iodide of potassium, have better claims 
to notice, although their power to dissolve cacoplastic and aplastic de- 
posits in the body is very uncertain. The occasional subsidence of exter- 
nal scrofulous tumors under their use is the best argument in their 
favor ; and they have this advantage, that when judiciously administered, 
they do not injure the blood or the constitution. They act best, and are 
longer borne, when combined w^ith some amylaceous or mucilaginous 
material, such as decoction of Iceland moss, or fluid extract of sarsapa- 
rilla, to which may be added a little tincture of hop, or some other nar- 
cotic ; and I have found this combination frequently useful in the early 
stages of tuberculous disease, where there is no fever, active inflamma- 
tion, or tendency to hemorrhage. "Whether the iodine and alkali ever 
directly promote the solution or absorption of tuberculous matter, I am 
still in doubt ; but the signs of the presence of limited tubercles have, 
in many instances, diminished during their use, and the patients have 
regained color, flesh, and strength. Other combinations of iodine, par- 
ticularly with iron, have been recommended in scrofulous disease. The 
iodide of iron and other preparations of this metal, I have found very 
beneficial in cases of anaemia, or general weakness, without much fever 
or local inflammation ; but I have seen no reason to suppose that they 
promote the removal of tubercles already formed. 

568. But there are other agents which have been found of decided 
utility in cacoplastk and aplastic diseases, and we shall better under- 
stand their mode of operation if we again advert to the nature of the 
deposits, and consider what means are likely to promote their removal, 
by causing their solution or disintegration. Cacoplastic deposits consist 
of albumen or proteine, with a little (insoluble) gelatine, and minute mole- 
cules of fat contained in the granules. The more granular the deposit, 
and the lower in the scale of organization, the more do these fatty mole- 
cules abound ; and in opaque tubercle and atheroma they are so much 
increased as to coalesce and form large oil-globules, as well as some solid 
forms of fatty matter. The most efi'ectual solvent of all these consti- 
tuents are caustic alkalies, especially liquor potassse, which dissolves the 
proteine, and forms a liquid soap with the oil. But it is impossible to 
administer caustic alkalies in sufficient quantity to exert this solvent 
power through the blood, both because they would irritate the stomach 
and vessels in their passage, and they would soon meet with such an 
amount of acid, particularly carbonic acid, as to deprive them of the 
greater part of their solvent power. The same objection applies to the 
use of acetic acid, which has been recommended with a similar object. 

Other agents have been extolled which might be supposed to be useful 
by dissolving the fatty particles of tubercle, and thus promoting its dis- 
integration; of this class are naphtha or pyro-acetic spirit, oil of turpen- 
tine, tar, sulphuric ether, and various fixed oils. Naphtha, which has 
been so highly recommended by Dr. Hastings in the treatment of phthisis, 
has in my hands proved serviceable in a very limited number of cases, 
in which, by its efi'ect in checking profuse purulent secretion, and the 
cough, hectic, and wasting accompanying it, it has appeared to me to 



340 STRUCTURAL DISEASES. 

operate like the balsams, gum resins, and turpentines, ratber than by 
any specific influence on the tuberculous disease. So, like these, it often 
unduly checks expectoration, and excites pain and tightness of the chest, 
and hard cough, which have ended in inflammation or hemorrhage. 
Its utility is farther limited, like that of other medicines mentioned before, 
by its tendency to irritate or disorder the stomach. 

Fixed oils also possess a solvent power on the fat of tubercle, and they 
have no such irritating or active properties towards the textures as to 
deter us from using them in quantities much greater than can be given 
of any of the above-named agents, and sufficient to justify the inference 
that they do exercise a very marked influence on nutrition, and do there- 
fore thoroughly and abundantly pervade the textures of the body. But 
the greater number of fixed oils soon disagree with the stomach, bowels, 
or liver, causing nausea, inappetency, diarrhoea, bilious disorders, and 
other evil effects formerly noticed to result from excess of fat in food 
(§ 60), and this they appear to do in proportion to their proneness to 
absorb oxygen and become rancid, and therefore acrid, and often losing 
their fluidity. In these respects fish oils have greatly the superiority, 
being more permanently fluid and less liable to turn rancid, provided 
they be not contaminated with putrid matter in their manufacture 
(which is commonly the case, and they therefore require to be purified 
with animal charcoal). Of fish oils, experience chiefly testifies in behalf 
of that from the liver of the cod ; but analogy favors the supposition 
that spermaceti oil, and seal oil, if equally purified, would be not less 
eligible, and they would have an obvious advantage in their more 
abundant supply, and lower price.' But it is important that the oil 
should be as free from taste and smell as possible, and, for obvious 
reasons, I prefer that which by cooling and settling, or by filtration, is 
deprived of most of the stearine. Such an oil, given in doses gradually 
increased to a tablespoonful three times a day, in the great majority of 
cases, agrees well with the stomach and bowels, increases rather than 
impairs the appetite, and, if continued for some weeks or even months, 
promotes in a marked degree the function of nutrition, increasing the 
strength as well as the flesh, and giving increment to all 'the textures. 
Nor is this surprising when we consider that the nuclei or rudimental 
molecules of all structures appear to consist of fat (§ 523), which the 
oil in its highly divisible state, supplies and renews in the manner 
most conducive to active and healthy nutrition. Its peculiar fluidity 
and little proneness to change also enable it to pervade all structures, 
and to penetrate even into imperfectly organized deposits, and by 
softening their concrete fatty molecules, and rendering more permeable 
and su[)plc their whole mass, brings them more under the influence of 
the adjoining living parts, through the circulation in which, either their 

' I tliink it scarcely ncccssar}' even to advert to a supposition formerly general, and still 
entertained by a few, that cod-oil owes its efficiency either to its offensive impurities or to 
finy iodine which it contains. I will merely state that in some hundreds of cases in which 
1 have prescribed the oil, the best effects have generally resulteil from the use of the purest 
kind ; and in many of these cases various forms of iodine had been exhibited without pro- 
ducing any of tliosc marked changes which followed the taking the oil. 



•TREATMENT. 341 

vitality and nutrition are improved and maintained, or, if incapable of 
improvement, they are gradually dissolved and absorbed away. 

Such appears to me the mode of operation of the cod-liver oil, assur- 
edly the most efficacious of all medicinal agents in the treatment of 
cacoplastic and aplastic deposits, and one which, after two years con- 
stant experience in its use, is still frequently surprising me by the 
wonders that it occasionally works even in aggravated and advanced 
cases of scrofula, mesenteric disease, pulmonary consumption, chronic 
pneumonia and pleurisy, and chronic rheumatism. 

But no remedy, however beneficial, should lead us to neglect atten- 
tion to those general and hygienic measures by which the constitutional 
health is promoted and sustained ; or, in other words, the great func- 
tions of circulation, respiration, digestion, absorption, and excretion are 
promoted. Mention has so often been made of these measures, that it 
is needless to specify them again ; and we may conclude this subject by 
adverting to means which may promote the absorption of cacoplastic 
and aplastic deposits. 

That such absorption does take place, is indisputably proved by the 
changes in chemical composition, as well as in physical condition, that 
these deposits undergo in process of time (§§ 556, 561). The most 
salutary of these changes, and the absorption of the most injurious part 
of the deposits, are promoted by as free and active a circulation through 
and near the affected part as can be carried on without inducing irrita- 
tion or hyperemia. Hence the utility of regular exercise, and of fre- 
quent friction of the surface in the vicinity of the seat of the deposits, 
sometimes aided by rubefacient applications or salt-water aspersions. 
The more active circulation thus excited promotes the gradual solution 
of the deposits, chiefly by the oxidating current of arterial blood that it 
directs through their neighborhood ; and the inquiry naturally suggests 
itself, can we aid this process of solution by means which oxygenate the 
blood more highly than can be done merely by free respiration of pure 
air ? I have before surmised that it is probable that such agents as 
nitric and nitromuriatic acid and chlorate potass, may contribute to 
this object ; and I now mention them because I have found their con- 
tinued use beneficial in many cases after inflammation, in which circu- 
lation and absorption were slack, and cacoplastic effusions were accu- 
mulating and threatening mischief. So likewise in scrofulous and tuber- 
culous disease, during the maturation and softening of the deposits, 
these oxygenating medicines sometimes produce decided improvement 
in the general and local symptoms. Their utility is limited by their 
tendency to irritate the alimentary canal when given largely or con- 
tinued long ; but they may commonly be advantageously used at inter- 
vals, when courses of cod-liver oil or of iron and other tonics are inter- 
rupted. Farther details belong to special pathology and treatment. 

[The evidence in favor of the curability of phthisis seems to accumu- 
late and to inspire us with fresh hopes and new expectations. Laennec 
first showed on pathological grounds that pulmonary tubercular cavities 
were susceptible of cure ; and the observations of Andral are confirma- 
tory. Boudet states that he met with fourteen cases in the space of 
a year, in which there were all the evidences of softening and of the 



342 STRUCTURAL DISEASES. 

presence of a cavern, whicli Lad ultimately dissappeared. Another 
mode of cure is by the retrocession of tubercle, and its conversion into 
calcareous or pultaceous concretions (§ bbQ). Dr. Hughes Bennett has 
attempted to show that the cure of phthisis in this way is more frequent 
than is generally thought ; and he supports his opinion by numerous 
statistical data/ Dr. Deeper says that, "during a period of six months, 
while acting as pathological assistant in the Edinburgh University, he 
noticed the presence of these cretaceous remains in the lungs of nine 
individuals who had died in the Royal Infirmary of other diseases." 
Dr. Blakiston has reported several cases of the complete arrest of 
phthisis, not only after unequivocal signs of solid deposit at the summit 
of the lungs, but in which actual cavities had existed during life. See 
his valuable work on Certain Diseases of the Chest. Philadelphia, 
reprinted, 1848.— C] 



MORBID GROWTHS. 

569. Under the term morlid groivths, or tumors^ may be arranged 
certain structures developed in the animal body in addition to the natu- 
ral textures. They differ from hypertrophy and euplastic deposits in 
the peculiarity of their structure; and from cacoplastic and aplastic 
deposits, in their possessing a higher degree of organization. In other 
words, they differ from hypertrophy and euplastic formations in their 
hind of vitality; and from degenerations and cacoplastic deposits in 
their degree of vitality. They are, in fact, new structures ; and although 
some of them in general characters, and most of them in elementary 
composition, resemble some of the natural textures of the body, and 
although all derive their nourishment from the blood, yet, in their ori- 
gin and growth, they are more essentially distinct from the natural 
structures than are any of the results of diseased nutrition hitherto 
considered. For these reasons, they have been called new and para- 
sitical growths ; and the i^xxo. parasitic al is the more applicable to them 
because their existence and mode of growth cannot generally be traced 
to variations in the local circulation, which we have found to be chiefly 
concerned in producing and influencing the modifications of nutrition 
hitherto noticed. 

Morbid growths have been divided into analogous^ those whose struc- 
ture resembles some natural texture (including false membranes, &c.) ; 
and non- analogous, or heterologous, those which have no parallel in the 
healthy state of the animal economy. But this division is inconvenient 
because it is applied to the other products of diseased nutrition pre- 
viously arranged under another division (hypertrophy and deposits); 
and it is often inapplicable, inasmuch as many morbid growths are 
essentially compound, comprising some forms that resemble natural 
textures, others that do not ; yet all these are constituted of similar ele- 
mentary molecules; this remark especially applies to carcinoma. 

The division which I have adopted into no?z-ma%naw^ finU malignant 

» Kdin. Med. and Surg. .Jouru. No. 1G3, April, 1815, p. 40G. 



NON-MALIGNANT GROWTHS — CYSTS, ETC. 343 



is more useful in a practical point of view, although it may not be easy 
to make it precisely applicable to all cases. 



SECTIOX YII. 

NON-MALIGNANT GROWTHS. 

570. I would apply the term non-malignant to those growths, or 
tumors, which occur in a part of the body, without tending to infect 
other parts; and which arise among, but do not invade or penetrate the 
natural structures; and, if they prove injurious, it is by their bulk or 
position,' or by the extent to which they abstract the nourishment of 
the body. 

571. The most simple forms of new growth are serous cysts^ which 
consist of a shut sac, "containing serum, and formed of condensed cel- 
lular substance resembling serous membranes, which are formed gradu- 
ally around a clot of blood, or any foreign substance in the system; and 
are frequently developed spontaneously in various parts of the body. 
They are frequently attached to the natural serous membranes, but 
sometimes quite separate from these; sometimes solitary, sometimes set 
together in clusters ; and their size and shape are very various. They 
must be distinguished from enlargements of natural cavities, such as the 
calicos of the kidneys, or Graafian vesicles in the ovaries. They are 
often unconnected with disease of the adjacent textures ; but in some 
cases, these textures are found either wasted by absorption (atrophy 
from pressure, § 532), or disorganized by inflammation around them. 
There is no evidence of their being generally connected, in their com- 
mencement, with inflammatory action; and when they are small, their 
existence is often not denoted by any symptoms whatever."^ 

Besides the instances above excepted from thi'S class of new growths, 
may be mentioned several others, which are rather instances of hyper- 
trophy, dilatation, or unusual development of a natural structure, and 
therefore belong to a former division (§ 528). The enlarged bursre, in 
parts subjected to pressure ; the dilated mucous follicles, in the cervix 
uteri; the cutaneous follicles distended with fatty or other matter (epi- 
dermis scales), constituting the subcutaneous adipoma and meliceris ; 
the salivary ducts obstructed, and filled with concretion, in the tumor 
called ranula, are of this kind, and do not belong to the present divi- 
sion. I would, with Dr. Hodgkin, extend the same remark to the small 
serous cysts frequently found in the kidneys and liver, which I have 
before described as portions of secretory ducts obstructed and distended 
with serum, (p. 193, note.) It may be fairly questioned whether other 
serous cysts are not also due to enormous enlargement of the primitive 
or compound cells of which textures are partly composed. My friend, 
Dr. Hodgkin, has most plausibly advocated an opinion of this kind, and 
has applied it also to explain the production of more solid and complex 

^ Alison's Outlines of Pathology, p. 201. 



344 STRUCTURAL DISEASES. 

growths, by the formation, multiplication, and compression of a series 
of cells. ^ 

572. Cysts, somewhat like the serous cysts above described, are some- 
times found filled with different unorganized contents, and then coiisti- 
tute the simplest kind of encysted tumors^ which form in various parts 
of the body that have a cellular structure, and they have received 
names descriptive of their contents : liygromo.^ when they contain a 
nearly serous fluid, and form encysted dropsy, if they attain a large 
size; hsematoma^ when their contents are bloody; steatoma, or lipoma, 
when they are of a fatty nature; and atheroma, when they contain an 
opaque pulpy matter of plaster-like appearance. 

These cysts are probably often formed in the first instance of extra- 
vasated blood or fibrinous matter, the exterior of which becomes organ- 
ized into a sac, the inner surface of which, according to Yogel, secretes 
an epithelium ; whilst the interior is more or less removed, and either 
gives place to serum, which maybe more or less thickened by epithelium 
scales, or may become converted into fatty or even osseous matter, in 
the same manner as aplastic deposits (§ 561), and the contents of old 
abscesses.^ When such tumors form under the skin, they often contain 
epidermis scales, which may render their fluid opaque and thick, or by 
agglutination may concrete into a horny solid. In the vicinity of 
hairy parts, they often contain hair. In some instances cholesterine 
has been found in them in great abundance; not only in cysts connected 
with the liver, but in those large and often compound cystiform tumors 
connected with the ovaries. In these last organs, cysts have also been 
found inclosing perfectly formed teeth and bones, as well as hair. 

573. Complex cystiform tumors are more complicated in their struc- 
ture exhibit farther deviations from the natural organization. They 
are chiefly developed in connection with glandular organs or those hav- 
ing c^^sts or vesicles, as the ovaries. 

A still more complex and organized kind of tumor, is that generally 
designated by the term sarcomatous, wdiich consists of organized solids 
of considerable variety, but generally bearing a resemblance to one or 
more structures naturally existing in the body, and generally in the 
part in which the tumor grows. Thus we have fibrous tumors, consist- 
ing of densely compacted fibres, scantily supplied with bloodvessels, 
generally slow in their growth, and like fibrous deposits liable to ossifi- 
cation. Steatoma, or adipose sarcoma, which resembles natural adipose 
texture ; but is often rendered more dense by combination with a fibrous 
structure ; — Chondroma, or cartilaginous tumor, which forms rounded 
masses having much analogy to cartilage, but may also be combined 
with hands of fibrous texture, and are liable to ossification ; — Vascular 
tumors {llvcmatoma, erectile tumors), which consist of a congeries of 
bloodvessels of considerable size, apparently enlarged capillaries, with 
more or less connecting filamentous tissue. These last present varieties 

> McrL-Cliir. Trans, vol. xv. part 2. 

2 Vogcl suggests that similar cysts with various contents may originate in old abscesses 
which have never opened, an«l tlie pus in them has gradually undergone a change. Cysts 
in the liver, containing a gelatinous, and in some instances a putty-like matter, commonly 
passing for tubercle, appear to have been produced in this mode. 



NON-MALIGNANT GROWTHS — HYDATIDS. 345 

dependent on the freedom with which they communicate with arteries ; 
when supplied by large arteries they are florid in color, they pulsate, 
and if large, the pulsation is attended by a blowing or rasping sound as 
in vascular bronchocele ; when the arterial communication is not free, 
the tumors exhibit the darker hue of venous blood. ^ 

Dr. Hodgkin considers that the complex cystiform tumor, as it occars 
in the ovary, exhibits a type of the origin of morbid growths in general, 
not excepting those of a malignant kind. From the internal walls of 
one original, or parent cyst, there spring a number of other cysts, vary- 
ing in their contents; and as they grow, they fill the original cyst, and 
project beyond it, other cysts being produced within them; and thus a 
growth takes place, subject to modifications from the nature of the tex- 
ture which is its seat, as well as from the contents of the cysts. In solid 
structures, as dense cellular membrane, the cysts are so compressed as 
to present the appearance of fibres radiating from a centre, and they 
lose all their lic^uid contents. The adjoining textures, as well as the 
w^alls of the cells, may also inflame and cohere, so as to obliterate the 
cystiform structure of the tumor. 

574. The pathological cause of morbid growths is involved in much 
obscurity. We cannot at present go beyond the supposition that they 
arise from altered vital properties in some of the molecules of the tex- 
tures in which they are developed ; so that, instead of being assimilated 
to these textures, and conforming to the laws of their growth and decay, 
these molecules grow of themselves in modes more or less peculiar, and 
more or less independently of the influences of the adjoining living parts. 
Where these modes are less peculiar and more dependent on the nutri- 
tion of the adjacent structures, the growths are less abnormal, vary less 
from these structures, and in their origin and course more resemble 
either hypertrophy (§ 525) or euplastic deposits (§ 547), and they do 
mischief rather by their size or situation than from their intrinsic 
nature. Where the mode of growth is more peculiar and more inde- 
pendent of that of the textures in which they arise, the resulting tumors 
are more abnormal in their nature and mode of development ; they ap- 
proach in character to malignant disease, acting injuriously, not only by 
their bulk and position, but also by abstracting the nourishment of the 
body, and by tending to supersede the natural structures. 

575. At the outer limits of the non-malignant growths, maybe classed 
those peculiar bodies called hydatids, or acephalocists. These are more 
peculiar in structure and contents than any other morbid growth, and 
they are quite detached from the structures in which they occur. They 
may, therefore, be inferred to possess a vitality quite independent of 
that of these structures. Their vitality is low, but indisputable, and is 
exhibited (1) in their power of self-nutrition, as manifest in the growth 
and the peculiar structure of their walls, which are much more elastic 
than any normal animal texture ; (2) in their power of secretion, shown 
by the peculiarity of their contents, which are limpid and colorless, what- 
ever be the nature of the matter in the serous cyst which separates them 

^ For farther particulars respecting tlie pathological character of tumors, see Vogel's 
Pathological Anatomy, by Dr. Day, [Philadelphia, reprinted, 1847.] 



346 STRUCTURAL DISEASES. 

from the living textures ; (3) in tlieir power of reproduction by gemma- 
tion, the young being developed between the layers of the parent cyst, 
and thrown off, either internally or externally, according to the species. 
Professor Owen^ describes the hydatid to be " an organized being, con- 
sisting of a globular bag, which is composed of condensed albuminous 
matter, of a laminated texture, and containing a limpid colorless fluid, 
with a little albuminous, and a greater proportion of gelatine as sub- 
stance." He adds : " As the best observers agree in stating that the 
acephalocyst is impassive under the application of stimuli of any kind, 
and manifests no contractile power, either partial or general, save such 
as evidently results from elasticity — in short, neither feels nor moves — 
it cannot, as the animal kingdom is at present characterized, be referred 
to that division of organic nature. It would then be a question, how 
far its chemical composition forbids us to rank the acephalocyst among 
vegetables. In this kingdom, it would obviously take place next those 
simple and minute vesicles, which, in the aggregate, constitute the green 
matter of Priestley {protocoecus viridis, Agardh) ; or those equally 
simple, but different colored psycliodiarise, which give rise to the red 
snow of the arctic regions [j)rotococcus Jcermesianus). These, first-born 
of Flora, consist, in fact, of a simple transparent cyst, and propaga^te 
their kind by gemmules developed from the external surface of their 
parent." 

The researches of Schleiden, Schwann, and their followers, have 
thrown some light on the possible origin of hydatids, by showing that 
the primitive cells of animals, as well as of vegetable structure, are often 
not unlike hydatids in their anatomical composition, growth, and mode 
of reproduction ; for the hydatid appears to be a nucleated cell, from the 
interior of which are developed nuclei and nucleoli, the germs of young 
cells. But if it be presumed, in accordance with this fact, that hydatids 
are really offsets of living structures, capable of living detached from 
the solids of the body, it still remains a mystery how this divided or 
detached life is acquired by certain molecules on rare occasions, and 
contrary to the usual law. We might, perhaps, imagine some analogy 
between hydatids and the polype tribe of animals, which may be inde- 
finitely propagated by division ; and it might be conjectured, that the 
conditions of the body in which hydatids are most commonly found, 
might reduce the plasma of certain parts to the standard of this mode 
of life ; but these subjects are too speculative to be dwelt on here. 

576. The situations in which hydatids have been most commonly 
found, arc the liver, the lungs, the spleen, the kidneys, and the ovaries. 
M. Andral records an instance in Avhich he found hydatids in the blood 
within the pulmonary veins ; there was also a large cyst, full of hydatids, 
in the liver. The condition of the system in which they have been most 
frefiuently found to occur, is one of cachexia and malnutrition. They 
are usually contained in a serous or protective cyst (§ 571), formed by 
the texture around them ; and the symptoms which they occasion are 
merely those caused by their bulk and position, compressing, displacing, 
and irritating organs, and causing atrophy and inflammation of their 

' "Cyclopaedia of Anatomy," &c., article Entozoa. 



MORBID GROWTHS — TREATMENT. 347 

textures. In the cyst which contains them, there is commonly found 
more or less opaque laminated matter, which appears to be the debris 
of collapsed hydatids ; indeed, some of them retaining the globular form, 
often exhibit the commencement of this decay, in an opacity and wrin- 
kling of their walls, and a changed color of their contents. But I have 
likewise found a considerable quantity of an opaque, yellowish, pulta- 
ceous matter mixed with the collapsed hydatids, and lining the contain- 
ing cyst ; under the microscope it appeared to consist of granular mat- 
ter, and imperfect cells, with much fat ; and in one instance, where the 
hydatid's sac lay between the liver and the diaphragm, there were abund- 
ant crystals of cholesterine ; I therefore regard this opaque matter as a 
deposit from the surface of the sac, degenerated into aplastic and fatty 
matter. 

577. The echinococcus is a variety of hydatid, differing from the pre- 
ceding chiefly in its having a yellowish and tougher outer tunic, and in 
its containing distinct animalcules within it {yermiculus eehinoeocci). It 
has been found in the liver, spleen, mesentery, and substance of the 
heart, and rarely in the urine. The cysticercus is found in muscular 
structure, and in one instance was seen in the aqueous humor of the 
eye. It has a distinct structure, consisting of a cystiform body and a 
head provided with suckers and hook-like processes for attachment. The 
disto7na hepaticum^ or liver-fluhe^ is rarely found in the human subject. 
It is the supposed cause of the rot in sheep, and was found by Andral 
and Delafond in those animals in which dropsy was present, and there 
was a defect of albumen in the blood (§ 222). The rot is a disease which 
chiefly attacks sheep fed in wet clayey pastures. 

The subject of intestinal worms belongs properly to special pathology. 

578. Little can be said on the medical treatment of morbid growths. 
To those of the kinds most approaching to the natural textures may be 
extended the observations applied to hypertrophy (§ 529) and euplastic 
deposits (§ 552). So far as they originate from, or are augmented by, 
local determination of blood, or any other kind of hypergemia, the reme- 
dies for these morbid elements may retard the increase of the growths. 
But as we have found that the chief peculiarity and cause of these growths 
is an alteration of the vital properties of the primitive molecules of tex- 
tures, little is to be expected from measures which act only on the quan- 
tity of the nutritive material. In fact, we have seen that, in many in- 
stances, morbid growths seem to originate in connection with a depressed 
rather than with an exalted condition of the vascular functions ; and in 
those last noticed, which bear more distinctly the character of parasites, 
the general or constitutional powers are weakened in proportion as these 
are developed. Hence, the general treatment indicated in such cases is 
of the supporting and tonic kind, with due attention to the regulation of 
the digestion and of the secretion. But this treatment will require modi- 
fication when the morbid growths, by their irritation or pressure, excite 
a considerable amount of inflammation, or even of local obstruction to 
the circulation. 

We are not acquainted with any medicinal means of correcting those 
alterations of vital properties in the molecules or textures from which 



348 STRUCTURAL DISEASES. 

morbid growths take their rise. The same spontaneous power which 
places these growths beyond the controlling influence of the laws of tex- 
tural nutrition, removes them beyond the reach of general remedies. 
The surgeon can in some instances remove the diseased part by the 
knife, and can sometimes farther modify its properties by the direct 
application of escharotics, or caustics, which destroy the morbid cells or 
germs which are the roots of the growth ; and where this can be eifectu- 
ally done without serious injury to other living parts, the cure may be 
complete. Mechanical pressure carefully and steadily applied so as to 
diminish the supply of blood to the tumors without interrupting the cir- 
culation in other parts, has sometimes been effectual in restraining the 
increase, and in some cases in promoting the absorption of morbid 
growths. It is doubtful whether the physician possesses any means of 
aiding the surgeon in these cases, or of controlling morbid growths which 
are beyond the reach of the surgeon, farther than those calculated to 
13romote the general health of the body. 

In many instances, the secondary pathological changes induced by 
morbid growths, such as inflammation, congestion, dropsy, flux, &c., 
are the chief objects of treatment, and may often receive much benefit 
from the usual remedies; but the extent of this benefit is commonly 
limited, as to extent and time, by the permanency and intractability of 
the morbid growth, which is their cause. Thus with encysted dropsy 
of the ovarium, peritonitis, ascites, and oedema, obstruction of the intes- 
tines, and other secondary functional disturbances, generally admit of 
relief for a time; but as the ovarian tumor remains, and may increase in 
spite of all remedies, the resulting disorders recur again and again, and 
at last prove fatal. But the growth of the cysts themselves, although 
generally progressive, may be very capricious — being sometimes very 
rapid ; in other instances, even in the same case, it may remain station- 
ary for years. Nay, cases are not wanting, although rare, in which 
encysted tumors have altogether disappeared : as after the operation of 
tapping, or even spontaneously, by rupture, into some of the natural 
cavities. But such instances, although they show a variety exhibited 
by morbid growths, not to be forgotten in connection with prognosis as 
well as treatment, are to be considered rather as exceptional cases, than 
as those following the usual rule. 



SECTION VIIL 

» MALIGNANT GROWTHS. 

579. Malignant groivths are distinctly organized structures, arising 
in various textures of the body, invading these and contiguous textures 
with their own peculiar substance, and often appearing successively or 
simultaneously in several parts of the body. There is perhaps no cha- 
racter more indicative of malignancy than the disposition to pervade 
and penetrate the several structures of a compound organ, and even to 
form attachments to those adjacent, and thus to unite several distinct 



MORBID GROWTHS, MALIGNANT. 349 

textures and even organs into one morbid mass ; in this respect they 
contrast with non-malignant tumors and deposits, which push aside, com- 
press, or distend the structures in or near which they are developed, but 
never penetrate through them. Malignant growths thus prove injurious, 
and eventually fatal, not merely by their bulk and position (§ 569), 
but also by the change of structure which they may induce in various 
organs ; by the intractable ulcerations and fungous wounds to which 
they tend ; and, lastly, by a wasting and deleterious influence which they 
seem to exercise on the whole functions and structures of the body. 
In all these points, the most malignant growths exhibit a character per- 
fectly distinct from the more simple, harmless growths hitherto de- 
scribed ; but it must be observed, that the degree of malignancy varies 
very much in different cases, by one or more of the preceding charac- 
ters being absent, or not yet well developed ; and, consequently, that 
morbid growths or tumors are occasionally met with, which present a 
doubtful or intermediate character between non-malignant and malignant. 
580. The names cancer and carcinoma (from the supposed resemblance 
of the diseased structure to a crab, cancer^ xa-^xivo^^ which suggests the 
apt image of numerous claAvs penetrating and attacking adjacent parts), 
have been long applied to the whole genus of malignant growths, which 
comprehends the following varieties: Scirrhus ; mammary ^ pancreatic^ 
and solanoid sarcoma ; eyicephaloid, or medullary sarcoma ; fungus hse- 
matodes ; and colloid^ or gelatinous cancer. That these are all varieties 
of the same disease, may be inferred from the fact that they more or 
less resemble each other in the characters of malignancy above described; 
and that they frequently occur in the same subject, either simultane- 
ously in different parts, or successively in the same part. Thus a per- 
son who has long been affected with scirrhus of the breast, often dies 
wath medullary sarcoma in the liver or lungs; or after a scirrhous tumor 
has been removed from any external part, an encephaloid or fungous 
disease may subsequently appear in its place. The varieties may, for 
the most part, be traced to different degrees of activity in the specific or 
cancerous matter^ that may now be stated to be the materies morhi^ and 
to the varied changes in the new growth, and in the implicated textures 
which this matter, thus differently active, can produce. Of these varie- 
ties, it may be said generally, that scirrhus, and perhaps the mammary 
and pancreatic sarcoma, exhibit a chronic character, with less activity 
and tendency to increase locally, or to spread through the system ; 
whilst the others constitute the more acute forms of cancer, causing 
more rapid growth in the parts first affected, and more speedily appear- 
ing in other parts of the body. 

581. The peculiar matter of cancer is distinctly a structure consist- 
ing of nucleated cells and molecules, contained in an areolar or fibrous 
web of various density. Of these, the cells must be considerd the first 
elements; and although they present some variety in form, they are 
constantly found in every kind of cancer. These cells are chiefly glo- 
bular, and retain that shape in the soft, gelatinous kinds of cancer ; but 
in others, many are caudate, or spindle-shaped, as if in the process of 
transformation into fibres. Into scirrhus, and other . more solid and 
chronic forms of cancer the fibrous structure is more abundant, and is 



I 



350 STRUCTURAL DISEASES. 

very perceptible to the naked eye, forming glistening stride, or bands, 
radiating through the mass, of cartilaginous hardness; the cancerous 
cells and numerous granules are seen bet^Yeen these fibres and accom- 
pany them to their outermost branches. In the cerebriform or medullary 
kind of cancer, the nucleated cells are very numerous ; and the texture 
in ^^'hich they are contained is cellular, and well supplied with vessels. 
This is the species in which the growth is most rapid, and in which, 
from the extravasation of blood in the loose new texture, a bloody aspect 
is given to parts of it, whence the name fimgus hsematodes. 

582. The intrinsic disposition to grow, even at the expense of the 
nutriment of other parts of the body, which was mentioned to be a cha- 
racter of some formations not distinctly malignant (§ 574), is exhibited 
in a much higher degree in malignant structures, the increase of which 
may take place most rapidly when all the natural textures are wasting 
away. This fact again suggests the idea of an independent vitality pos- 
sessed by these structures, in virtue of which, like parasitic animals or 
plants, they luxuriate at the expense of the whole frame. The question 
next arises : Are these growths truly parasites, arising from ova or 
seeds derived from without the body, and after entering it, and finding 
a proper nidus, or soil, taking root or becoming developed as a distinct 
being like worms or hydatids, and drawing its nourishment from the 
fluids and solids of the body ? If it be objected that malignant growths 
are too closely attached to, and too much identified with, the textures 
of the body to permit the notion of a distinctness of being, it may be 
replied, that cancerous cells, their most distinctive part, are often loose 
and unattached ; they propagate themselves by the production of young 
cells within them ; and in this mode become disseminated, first in con- 
tiguous parts, in which they appear to take root and extend their 
attachments ; and subsequently, through the channels of the blood- 
vessels, which in extensive forms of the disease have been found to con- 
tain cancerous masses. An experiment of Professor Langenbeck was 
supposed to have proved that the cancerous pulp containing these cells 
is capable of propagating cancer in animals on being injected into their 
veins, but the attempt has been frequently made by others without any 
such result. Should such an experiment be made to succeed, it would 
positively identify cancer with contagious diseases, respecting the causes 
of which we formerly noticed questions lika the present, as to their 
parasitic nature (§ 99). Contagion is not, however, a common cause 
of cancer ; the only example ever adduced being the rare one of the 
penis becoming infected by a carcinomatous os uteri. Farther, .it has 
been vrell remarked, by Dr. W. Budd,' that the causes which have been 
supposed to induce cancer are not such as can, in any intelligible way, 
favor the introduction of germs from without the body. Thus, in chim- 
ney-sweeps and others, the continued application of soot has been 
observed to be followed by the occurrence of cancer in the scrotum, in 
such a number of cases as to justify the inference that it has been the 
exciting cause. The often repeated contact of a tobacco-pipe with the 
lip, has also been considered a cause of cancer of that part. But 

' Kemarko on the Pathology and Causes of Cancer, Lancet, May 28, 1842. 



MORBID GROWTHS, MALIGNANT — CANCER. 351 

neither of these causes can, in any conceivable way, promote the de- 
velopment of cancer from extrinsic germs. 

The alternative that presents itself is, that cancerous growths may 
arise from a peculiar perversion of the natural nutritive process, similar 
to those modifications which we have been induced to suppose are the 
causes of the more peculiar kinds of common growths ; but in the case 
of malignant disease, the perversion is much greater in degree, and 
shows itself, not only in its origin, but in its whole subsequent history. 
It can be conceived possible, that causes long acting locally, as the soot 
on the scrotum of chimney-sweepers, the tobacco-pipe on the lips of 
inveterate smokers, the irritations of the stomach connected with habi- 
tual dyspepsia, and of the uterus from irregular menstruation, &c., may 
induce this extraordinary alteration in the molecular nutrition of these 
parts; but we cannot hereby at all explain the peculiarity of this altera- 
tion, which must therefore be viewed as an ultimate fact in connection 
with nutrition. In other words, if we assume that cancer-cells are mo- 
difications of the natural cell-germs by which textures are produced and 
nourished, we do not thereby explain (or refer to a known law) the ex- 
traordinary anomalies of the independent vital properties and consequent 
growth of these modified cells, which are obviously different from that 
of texture cells in general, and derive much of their destructive effects 
from such difference. It remains for future investio-ation to establish 
the law of that difference. We have before stated, that Dr. Hodgkin 
has proposed a plausible hypothesis with regard to these and other 
growths, that they originate in cysts (not cells or microscopic cysts, but 
larger ones, which comprise these) ; and that the multiplication of these 
cysts within each other, their prolongation into radiated fibres, their 
pressure on adjoining textures, and consequent inflammation, induration, 
ulceration, atrophy, or gangrene of these textures, comprise the whole 
history of malignant growths. What appears to me to be chiefly want- 
ing to establish Dr. Hodgkin's views, is a more distinct demonstration 
of the supposed cysts, which, at the commencement, or at the outer 
limits of cancerous growths during their spread, ought to be distinctly 
visible. 

583. But although the precise origin of malignant growths is still a 
matter of uncertainty, some important practical facts may be gathered 
from their pathology. Their microscopic structure and history pretty 
clearly show that they are of local origin ; that they extend by the 
multiplication of their cells, which, by perverting the nutrition of the 
adjacent parts, cause the growth of the tumor ; that they ultimately 
infect other parts of the body, by spreading to the nearest lymphatic 
glands, and by the mixture of their cell-germs with the blood (§ 259), 
which form new tumors in the liver, lungs, or other vascular parts, 
(the same as those in which purulent deposits take place, and for similar 
reasons) (§ 470) ; or the cancerous matter is sometimes found in clots 
within bloodvessels, or in the coagulable lymph effused by inflammation.^ 



' In a case (wliicli I sa"V7 -n^ith Mr. Ayeiy) of malignant disease of the lungs and deep 
cervical glands, inyolving the 8t]i nerves, there had been recent plenrisy, and the bands of 
false membrane were glistening, and grated under the scalpel from the presence of cancer- 
ous fibres. 



352 STRUCTURAL DISEASES. 

But the history of malignant gi'owths comprises not only that of the 

development of the cancerous structures in different degrees and forms, 
but also their effect on the adjacent textures; and it seems to me possible, 
by a due regard to these two elements, to explain much of the varieties 
which cancerous disease presents. Thus scirrhus is the slowest form of 
the disease, because it generally occm's in persons above the age of forty, 
in whom the textural nutrition is tardy, and the cancerous matter is but 
slowly developed : the effect on the adjacent textures is to excite infiam- 
mation of a chronic form, and therefore leading to induration, and often 
to contraction (§ 479), and more or less obliteration of the natural tex- 
tm'es. Hence the hard, knotty, corrugated swelling of scirrhus of the 
mamma, rectum, pylorus, &,c., which may be attended with more or less 
pain of a peculiar stinging or lancinating character, besides various 
functional disturbances (obstruction to the passage of food or feces, 
severe dyspepsia, vomiting, kc). The continuance of irritation in the 
indurated parts leads (as usual) to ulceration (§ 466). This constitutes 
what is called ojjen cancer, with ragged, inverted, or everted edges, and a 
fungous or sloughy interior, discharging a dark, offensive, ichorous mat- 
ter. That such ulcers should be wholly incapable of healing is quite 
intelligible, when it is remembered that its walls are composed of the 
cancerous structure and the compressed remains of the natural textures, 
whose secretions are too poor and too much perverted to afford euplastic 
secretion. The ulcer may prove an outlet for the increasing cancerous 
matter ; and if the discharge be checked by external means, the disease 
is more likely to spread or to attack other parts. As the ulceration destroys 
the indurated mass, and thus removes the barrier between the cancerous 
germs and the healthy textures, there is a greater chance of the body 
becoming more generally infected. Hence, too, from the multiplication 
and diffusion of the germs, the secondary malignant growths that may 
appear in other parts are often of the softer, more rapidly-growing kinds. 
The influence of scirrhous cancer on the whole frame, although more 
slowly induced, perhaps for this very reason, is carried to a greater degree 
than that of any other form of cancer. Emaciation sometimes reaches 
a point unequalled in any other disease ; and the wasting, of which this 
is the sign, extends to the composition as well as to the bulk of organs 
and textures. Thus bones lose much of their animal matter, and become 
so brittle, as sometimes to be fractured from the slightest violence. All 
membranes become extremely thin: the omentum often wastes away, 
excepting a few threads. The lungs exhibit a remarkable lightness, in 
weight and color; and I have seen the old cicatrices, or consolidations, 
so frequently found at their summits, thinned and almost as pliant as other 
parts of the pulmonary texture.^ But nothing is more remarkable than 

' It appears to me that the rare coexistence of tubercle with cancer, as noticed bj some 
Trriter?, is to be ascribed to the formerbeing removed bvabsorjjtion during the extraordinary 
wasting of textures which attends chronic cancer. I have tTvice found, in the bodies of 
persons who died of cancer, considerable remains of tuberculous deposit at the apex of the 
lungs, without any tubercles in other parts. In one case, masses, partly caseous, partly 
calcareous, of the size of a pullet's and a pigeon's egg, were thus found encysted by a thin 
membrane. In another, a cavity communicating with the bronchi, traversed by a band of 
dense ti.=sue. like that found in tuberculous cavities, and lined with a thin, smooth mem- 
brane, was in the middle lobe. In all these cases the other parts of the limgs were free 



MORBID GROWTHS, MALIGNANT — CANCER. 353 

tlie exsanguine state of the textures generally ; and this condition is 
obvious during life in an extreme pallidity, often associated with a sal- 
lowness, or peculiar lemon-tint, of complexion, that has been observed to 
be peculiar to cancerous subjects. 

Scirrhus chiefly occurs above the age of forty; and the more advanced 
the age, the slower generally is the progress of the disease. It has been 
remarked, by Sir Charles Bell, Sir Astley Cooper, Mr. Travers, and 
others, that scirrhus of the breast, which will run a comparatively rapid 
course at the age of forty-five, will remain stationary for years, and 
hardly appears to shorten life at the age of sixty or seventy. This shows 
the share which activity of textural nutrition has in causing the increase 
and dissemination of cancerous disease. It is under such circumstances 
that operations for the removal of the disease have been most successful ; 
but it must be remembered, also, that in such cases they are less strongly 
called for. 

584. The pancreatic mammary lardaceous (or pork-like), and solanoid 
(or potato-like), forms of cancer appear to be intermediate between 
scirrhus and encephaloid disease, i«Qcreasing more rapidly than the former, 
yet approaching to it in firmness. They are attended with less pain, 
from the smaller degree of tension and induration which they cause in 
the implicated textures. For the same reason, they are less disposed to 
ulcerate (§ 466) or slough (§ 474) ; and they commonly prove fatal, 
either by their growth and encroachment on some vital part, or by lead- 
ing to the dissemination of cancerous deposits in other parts of the 
system. 

585. Encephaloid (brain-like), or medullary sarcoma^ is the acute or 
rapid variety of cancerous growth. It occurs chiefly in young and mid- 
dle-aged subjects, and in the most vascular textures ; and it may be 
fairly connected with the activity of their molecular nutrition. This 
may be the cause of the rapid increase of the cancer-germs, or cells (if 
these be indeed mere modifications of the cell-germs of textures) ; and 
their elongation and growth into remarkably large and sometimes branch- 
ing fibres, forming the stroma or web of the cancerous growth ; but much 
of the speedy increase and early dissemination of this variety of cancer- 
ous disease, must be attributed to an active plastic process, which the 
presence of the cancerous matter excites in the vascular textures in 
which it lies. The mass of encephaloid tumors comprises false mem- 
branes, lymph, and even coagula of blood, in various degrees of organi- 
zation ; among and between these are found the cancerous cells and 
fibres, which luxuriate and rapidly multiply in so fertile a soil. It is in 
connection with tumors of this kind that the fact before noticed has been 
observed, that coagula in the neighboring veins have exhibited the ence- 
phaloid appearance ; and so has coagulable lymph produced by inflam- 
mation of serous membranes or parenchymata of organs. The speedily 
destructive influence of this kind of cancer is mainly to be ascribed to 

from tubercles. No-w, it does not appear probable that such considerable tuberculous deposit 
should have taken place without some in other parts also. We meet with no case of recent 
tubercle thus limited to one portion of the lung. These and similar facts connected with 
the emaciation of old age, seem to me to furnish additional arguments in faTor of the 
absorption of tubercles (§ 561). 

23 



354 STRUCTURAL DISEASES. 

the rapid dissemination of the cancerous matter, and the bulky deposi- 
tion which it induces around it, which, although organized, and highly 
vascular, are beyond the controlling influence of the powers of assimila- 
tion or absorption, and consequently penetrate, obstruct, or compress 
organs to a fatal extent. The facility of growth in these tumors receives 
some explanation in the varicose condition of their vessels, as ascertained 
by Mr. Kiernan, and their free communication with arteries. (§ 420), as 
pointed out by Schroeder Yan der Kolk. The same circumstance, to- 
gether with the general softness and looseness of their texture, accounts 
for the facility with which hemorrhage takes place into their substance 
(§ 357), causing an appearance that has led to the use of the term fim- 
gus Jisematodes. These forms of disease commonly prove fatal before 
the emaciating effects, so remarkable in scirrhus, have advanced far. 

586. The colloid^ or gelatinous (areolar of Cruveilhier) variety of can- 
cer seems to me to represent the cancerous element almost in a separate 
state, little mixed with natural tissues or their products. According to 
Muller, it consists chiefly of cells contained in a very slight loose web ; 
the cells are larger and rounder than usual, and contain small cells, 
which also contain cell-germs. The peculiar germinal principle of can- 
cer is here, therefore, very abundant and prolific ; but the nutritive se- 
cretion of the surrounding textures is not equally copious ; therefore no 
distinct growths are formed ; but the gelatinous matter is found infil- 
trated into the webs of textures, chiefly in connection with advanced 
stages of other forms of the disease. 

Farther varieties have been described, by Dr. Carswell and others, 
according to the particular form which the cancerous growth assumes, 
such as the tuhe7nfo7nn, stratiform, ramiform, &c. They are probably 
connected with the anatomical construction of the parts in which they 
appear, together with the quantity and rapidity of development of the 
new growth.^ 

[In the very interesting paper of Dr. Hughes Bennett, in the JEdin- 
hurgh Montldy Journal, the anatomical characters of cancer are thus 
described. A cancerous growth may contain the following elementary 
structures : 1. Molecules and granules ; 2. Nucleated cells of various 
shapes ; 3. A filamentous or fibrous tissue ; 4. A viscous fluid ; 5. 
Bloodvessels; 6. Fatty matter ; 7. Pus, and compound granular cells; 
8. Black pigmentary matter ; 9. Earthy matter. Of these, some are 
accidental or only occasional, and others essential or invariably present. 
The essential elements of cancer are: 1. A fibrous meshwork, or stroma; 
2. Nucleated cells ; 3. A viscous fluid in which these float. 

The fibrous tissue of cancerous growths exactly resembles that found 
in lymph or in the healthy tissues of the economy. It may be formed 
either by deposition or by means of cell-growth. In the former case, 
filaments more or less delicate, and closely aggregated, may be seen 
crossing each other, or running in bundles, forming various kinds of 
mcshworks, in which the cells of cancer are deposited. In the latter 

' Many iritorostinfr pMrlicnlnrs respecting the microscopic characters of cancer will be 
found in Vo^oI'h PatlioUtrjicjil Anntoviy (l)y l)r. Day), and in the Edinbvrgh Monthly Jour- 
nal, by Dr. Iluglics Jiennett, October and November, 1847. These have appeared since 
the publication of Dr. Walshe's elaborate Trcatiac on Cancer. 



MORBID GROWTHS, MALIGNANT — CANCER. 855 

case we can observe fusiform cells splitting up into fibres, and are able 
to trace their formation from round, oval, or caudate cells, until perfect 
fibres are formed. These cells (called by Lebert, fihro-plastic) are of a 
round or oval form, varying in size from the 1-lOOth to l-50th of a milli- 
meter in diameter. Sometimes they possess a distinct nucleus, about 
the l-130th of a millimeter in diameter ; at others, contain only several 
molecules and granules. Acetic acid causes these bodies to undergo 
very" little change. They become somewhat paler, but there is no 
marked diiference in this respect between the nucleus and cell-wall. 
These cells, in their different stages of development into fibres, have 
been frequently mistaken for those of cancer. MUller placed them 
among cancerous growths ; and hence the erroneous opinion that the 
caudate, or spindle-shaped cell is characteristic of cancer. Fibrous 
tissue may be arranged so as to form loculi, containing a viscous fluid 
with or without cancer-cells, constituting the colloid tissue of authors. 

The nucleated cells peculiar to cancer vary greatly in shape and size. 
Sometimes we see nothing but oval bodies about twice the size of a 
human blood-globule, or closely resembling, except in color, the oval 
blood-corpuscles of the lama or camel. They measure about the 1-7 5th 
of a millimeter in length, and 1-lOOth or l-120th of a millimeter in 
breadth. These oval bodies are the nuclei of cancer-cells. Sometimes 
they exist alone ; at others we may observe, by careful management of 
the light, a round or oval delicate cell-wall, frequently resembling a mere 
shadowed halo, in the fluid in which it floats. On adding acetic acid 
to them, we find the cell-wall disappear, whilst the nucleus becomes 
more distinct than formerly. Such is the character of a cancer-cell in 
its young state. At a more advanced period of development, the cell- 
wall is more distinct. The nucleated structure is now round or oval, 
its medium diameter being about the l-50th of a millimeter, with a round 
or oval nucleus about the 1-lOOth of a millimeter in diameter. The 
addition of acetic acid always produces a remarkable change in these 
bodies, causing the cell-wall to become very transparent and faint, and 
the nucleus to assume an unusual degree of distinctness. Hence Dr. 
Bennett considers that Dr. Walshe has committed a fundamental error 
in his histology of cancer, when he says (p. 33 of his treatise) that "the 
ultimate microscopical cells of cancer are insoluble in cold and boiling 
water, and are not seriously affected by acetic acid." 

Dr. Bennett minutely describes the farther growth of these cells, 
showing how they multiplied from cell rising within cell. It is owing 
to this cellular structure that cancer owes the reproductive power which 
constitutes its malignancy. The cells occur insulated or in groups, 
surrounded by the other elements of the growth, but more especially by 
the fibrous tissue. 

The third essential element in cancer is a gelatinous fluid. On cutting 
through a scirrhous tumor, however hard it may be, we may generally 
succeed in scraping from its surface a fluid more or less transparent. 
In soft cancer it is more abundant, and contains the granules and cells 
previously described. In some forms of cancer, however, it constitutes 
a very large proportion of the mass, presenting a gelatiniform or muci- 
laginous appearance, varying in color from a pearly white to a deep 



356 STRUCTURAL DISEASES. 

amber, and in consistence from a slightly viscous fluid to a firm semi- 
solid mass. Collections of this kind may occm^ in loculi formed by 
fibrous tissue, or in c^^stic tumors perfectly structureless, or containing 
only numerous molecules and granules constituting the simple colloid 
tissue of Gluge and Lebert. When associated with cancer, however, it 
contains a greater or less number of the cells previously described, in 
various stages of their development. 

It is the relative amount of the three essential elements of cancer 
now described which constitutes its peculiar form. If the fibrous ele- 
ment be in excess, it constitutes scirrhus. If the corpuscles be nume- 
rous, encephaloma is produced ; and if the fluid abound, and is collected 
into loculi, we call it colloid cancer. There is no other difi*erence be- 
tween these three forms than this. 

At an early period in the study of histology, it was natural to con- 
ceive that a certain /orm of the cell should be thought characteristic of 
cancerous growths. The observation of Mliller led to the belief that 
the caudate and spindle-shape of this minute structure was peculiar to 
them. Hence we find him confounding certain tumors long denomi- 
nated sarcomatose, and which wholly consist of fusiform cells, with 
cancerous or malignant growths. These, however, have no power of 
reproduction ; and, although often associated with cancerous cells, 
should not be confounded with them. From the results of many exami- 
nations. Dr. Bennett is satisfied that there is no one form of cell which 
can be considered as at all times characteristic of cancer. The caudate 
and spindle-shape of these bodies is common to fibrous structures in 
general, frequently seen in lymph, and especially in the exudation 
forming the granulations on ulcers, recent wounds, vegetations on the 
endocardium, &c. &c. 

The structure of the cell and the action of acetic acid upon it are 
much more distinctive. If the corpuscles are in that stage of growth in 
which they present a distinct nucleus with contained nucleoli, and if, 
on the addition of acetic acid, their external wall be rendered more 
transparent, whilst the border of the nucleus is apparently thickened, 
they are highly characteristic of a malignant structure. But even this 
is not an absolute and invariable mode of distinction ; besides, it is only 
applicable when the cells have arrived at a certain stage of development. 
Dr. Bennett has frequently seen young epithelial cells, under certain 
circumstances, present all the characters just mentioned, with the excep- 
tion of inclosed nucleoli, and undergo the same reaction with acetic 
acid. This is very apparent in some cases, where effusion has taken 
place into the lateral ventricles of the brain, when the epithelial cells 
of tlie choroid plexus become separated, swell out from endosmosis, 
assume a glo])uliir form, and the cell wall, if young, is partially dissolved 
in acetic acid, whilst the nucleus is unaffected. The same occurs with 
the epithelium of the bladder. He has found in the bladder a fluid hav- 
ing all the external appearance of pus, and on examination shown them 
to consist of round, oval, and caudate nucleated cells, exactly resem- 
bling those found in cancer, and acting with acetic acid in the same 
manner. Yet the lining meni))rane of the bladder, the ureters, and 
kidneys, were perfectly hcaltliy. ^Ve need not wonder, then, that epi- 



■CANCER. 357 

thelial cells liave frequently been mistaken for those of cancer, even by 
liistologists ; and that many growths, consisting of hypertrophy of the 
epidermis, or epithelium, as in several so-called cases of cancer of the 
lips, ulcerated warts, excrescences, &c., should have been mistaken for 
malignant growths. 

Dr. Bennett states that he is not aware of any tissue in which a 
fibrous and a cell-structure, such as has been described, were combined ; 
and he is, therefore, inclined to think that whenever we find cells of this 
kind deposited between the meshes of a filamentous structure, we may 
be satisfied that cancer is present. If we trust to the form of the cell 
alone, we may confound epithelial growths with cancer — if we trust to 
the fibrous elements alone, we may mistake sarcomatous growths for it. 
But in no case, so far as his experience has yet gone, can the two be 
associated w^ithout the existence of malignant growth. This character, 
then, he thinks one which will apply to all forms of cancer. In many 
cases the form and appearance of the cells, to an experienced eye, will 
be sufficient ; this more especially when they are fully developed, and 
the influence of acetic acid upon them observed. In difficult cases the 
conjoined character of the cells and fibres, and their relative position 
with respect to each other, will enable us to determine the point with 
more exactitude. To arrive at a knowledge of these facts, however, 
considerable skill in the manipulation of the microscope is necessary, 
and a very intimate acquaintance with the healthy and morbid tissues 
of the body. To distinguish the relative situation of the cells and fibres, 
especially w^hen mucous membranes are the object of investigation, a 
section, by means of Valentin's double-bladed knife, is also in most 
cases essential. — C] 

587, Another morbid production that has generally been classed 
among malignant growths, because it aifects many textures and may 
supersede them, is melanosis^ black cancer, or black tubercle. It most 
commonly occurs in the form of a loose cellular tissue filled wdth the 
peculiar black matter suspended in a serous liquid ; but sometimes its 
substance is quite compact and resembles crude yellow tubercle, or the 
lardaceous form of cancer. I have a drawing which I made of a lung 
exhibiting a combination of encephaloid disease with melanotic tumors, 
the latter of compact texture, like nodules of pulmonary apoplexy, and 
varying in color from a dark bistre brown to a deep jet black. The 
combination of melanosis with carcinomatous tumors has also been no- 
ticed by Cruveilhier and Carswell. Andral describes melanosis to occur 
in four forms : " (1) It pretty frequently constitutes masses, encysted or 
otherwise ; (2) the matter which composes it may, like the tubercular 
matter, be infiltrated into different tissues ; (3) it may be spread like a 
layer, of greater or less thickness, on the free surface of membranous 
organs ; (4) it may exist in the fluid state, either pure or mixed with 
other fluids."^ 

The peculiar characteristic of all these forms is the black matter, 
whichj from the analyses of Dr. Fyfe, M. Thenard, and M. Foy, ap- 

i Pathological Anatomj (Transl,), vol, i, ^. 249, 



358 STRUCTURAL DISEASES. 

pears to be a highly carbonized insoluble matter, supposed to be altered 
coloring matter of the blood. It has been compared by Andral to the 
black pigment of the eye, and he considers it to be identical with the 
black matter commonly found in the lungs and bronchial glands. The 
coloring matter of the blood certainly is sometimes changed into a per- 
fectly black matter, as in the black vascular striae and patches in the 
intestinal canal, particularly in chronic inflammation, where the blood 
has been effused or retained in vessels, and altered by the intestinal 
secretions and gases. These black appearances are called by Dr. Cars- 
well spurious melanosis. Again, the black pulmonary matter is merely 
a carbonaceous powder contained in the interstices of the textures, and 
sometimes in the vessels of the lungs and bronchial glands ; but whether 
it also proceeds from the coloring matter of the blood in an altered 
state, or is truly a deposit of carbon, is uncertain. All that is requisite 
to produce a black carbonaceous deposit in the coloring matter of the 
blood is the abstraction of a certain amount of hydrogen, which the 
mineral acids are capable of effecting ; and it seems not improbable that 
such a change takes place naturally in the formation of black pigment 
through the operation of peculiar cells (pigment cells), and as a result 
of disease in melanosis. 

But this production of black matter may coexist with various modifi- 
cations of the nutritive process ; plastic, as in cellular and membranous 
melanose tumors ; cacoplastic, as in the hard black tubercle, and in the 
black consolidation of chronic pneumonia ; and aplastic, as in the com- 
bination of black with opaque caseous matter, not unfrequently found in 
the lungs and bronchial glands. So, too, it may be, as we have seen, 
combined with various forms of malignant disease ; but, with Andral, I 
hesitate to class simple melanosis with malignant growths. 

588. The treatment of malignant disease has been generally considered 
to belong rather to surgery than to medicine, and 'yet the utility of 
removing malignant growths by operation, has been generally deprecated 
by surgeons down to the present time, when they may again learn, 
chiefly from the investigations of physicians, when and why operations 
may be expected to be successful. The indications of treatment which 
are suggested by the foregoing account of malignant disease, may be 
summed up under three: (1) to extirpate the malignant growth; (2) to 
retard its development ; and (3) to counteract its effects. 

The complete extirpation of malignant growths can be effected only 
when they arc quite local, so that, when removed by the knife or by 
caustic, no root or stray germs of the disease shall be left behind. We 
have adduced reasons to suppose that, at its first origin, cancer is en- 
tirely local, and that, if it be completely excised at an early period, a 
cure may bo effected. For this success, it is essential that every cancer- 
ous cell be removed; and Dr. Hodgkin has recommended the careful 
examination of the portion removed, to see that it contains on its sur- 
face none of those grains, consisting of an aggregation of canceroue 
cells, which can be seen, even with the naked eye, in cancerous struc- 
tures. Dr. W. Budd recommends the use of the microscope for the 
same purpose : "If the characteristic cells vrerc found on the cut surface 



MORBID GROWTHS, MALIGNANT — TREATMENT. 359 

of the portion removed, it would be morally certain that others have been 
left behind, and that the extirpation is incomplete, although, on the 
other hand, the absence of these cells would be by no means so sure a 
guarantee of their entire removal. Such an examination would, how- 
ever, always be a matter of great interest to the surgeon."^ The best 
security would lie in the operation being performed before the constitu- 
tion has been, in any degree, impaired by the disease ; and particularly 
before any neighboring parts, especially lymphatic glands, have shown 
any indications of disease. The best chance will, therefore, be afforded 
in cases in w"hich the growth is most chronic and inactive, and of the 
smallest extent, as in scirrhus of the lip, skin, or breast. If any can- 
cerous texture or germs are left behind, the operation is likely to do 
harm instead of good, by bringing them into activity, and developing 
the acute form of the disease. Cases have occurred, in which a can- 
cerous breast has been completely removed by a spontaneous sloughing ; 
but such an event is extremely rare. Cauterization is less advisable 
than excision, because less manageable. 

589. The second indication, to retard the development of the malig- 
nant growth, is chiefly to be attempted by means which diminish the 
circulation through the diseased part. Repeated local bleedings have 
been found useful, partly, perhaps, in this way, but more by relieving 
the inflammation excited by the growth. The best means of staying 
the growth of malignant disease is by pressure, which has long had many 
advocates. Such a kind and degree of pressure as will reduce the cir- 
culation through the part to the lowest degree compatible with its life, 
will pretty surely arrest the increase of the morbid growth, by depriv- 
ing it of its nutriment. But, for the utility of this measure, it is equally 
necessary that the disease shall not have extended to other parts 
besides those to which the pressure is applied; otherwise, in those parts 
which are commonly internal, the growth will proceed with an increased 
rapidity, proportioned to its suspension by the pressure on the outward 
part. The best means of applying pressure are those contrived by Dr. 
Arnott, especially the slack air-cushion under a compress. It is very 
doubtful that we possess any means of influencing malignant growths 
through the constitution. Various medicines have enjoyed an ephemeral 
repute for their efiicacy in cancer. Of these, conium has been one of 
the most favorite. Dr. A. T. Thomson considers the iodide of arsenic 
to possess some power in controlling the increase of cancer. But it is 
doubtful that any of these remedies do more than soothe irritation, and 
restrain common inflammation and its results, with which malignant 
growths are generally complicated. 

[Dr. Bennett does not coincide in the opinion that cancer is necessa- 
rily fatal, because it is not easy to understand why nature should never 
cause the degeneration and disappearance of this one particular growth 
alone, whilst every other tissue and form of cell-life, was occasionally 
abortive. Cruveilhier, Trousseau, Hodgkin, and others, have frequently 
traced the conversion of scirrhus into ossiform matter, in the lower ani- 
mals and in man. Dr. Bennett has seen this transformation in five 

1 Lancet, May, 1842. 



360 STRUCTUHAL DISEASES. 

cases, and he considers that they offer conclusive evidence that cancer 
is capable of undergoing the calcareous transformation. "It has been 
stated that cancer sometimes becomes transformed into fibrous or fatty 
tissue, and thus produces cicatrices in organs. It is very difficult to 
prove such a statement, because if there be no cancerous cells in a fi- 
brous tissue, it is contended that it is not malignant, and never has been. 
On the other hand, if cancer-cells be present, it is clear that we have 
no evidence of degeneration. There can be no doubt that many organs 
and tumors are considered cancerous which are only fibrous. Dr. Ben- 
nett has examined many so-called cases of scirrhus of the pylorus, which 
were only hypertrophy of the muscular and fibrous tissue of the part. 
He alludes to a case of Dr. Alison's he had examined, in which the 
coats of the stomach throughout varied in thickness from an inch to an 
inch and a half. The viscus was thought by all who saw it to be can- 
cerous, and yet he showed it to consist of nothing but fibrous tissue and 
fusiform cells. He had also proved many tumors supposed to be can- 
cerous to be only fibrous. Professor Bochdalek, of Prague, formerly 
pathologist to the hospital there, and now professor of anatomy in the 
university, published a memoir in 1845, On the Healing Processyf 
Cancer in the Liver. He describes the cancer in this organ as break- 
ing down into a cream-like matter, the fluid parts being absorbed, and 
the whole shrinking together, forming a puckering on the surface, often 
corresponding to a fibrous mass or a fatty material, in which collapsed 
cancer-cells may yet be detected. In some livers he has seen these cica- 
trices in all stages of formation, cancer in some places, and perfect 
cicatrices in others. In Prague, he tells us, there are between 400 and 
500 bodies examined annually. Among these, cancer of the liver 
occurs about 16 or 17 times, and among these, proofs of healing may be 
observed between 6 and 7. [Oesterreichische Wochenschrifty 26th 
April, 1845). Dr. Bennett has frequently seen these appearances in 
the liver, but he had never been able to satisfy himself that they were 
proofs of cured cancer. There are strong probabilities in its favor, 
however. Tubercular masses are rare in the liver of adults ; and such 
lesions must depend either upon cancer or upon chronic abscesses. 

Dr. Bennett considers that, taking every statement into consideration, 
it is by no means improbable that cancer might occasionally degenerate 
into a fibrous mass, although we still require positive proof of it. At 
all events, they have convinced him of tlie necessity of making farther 
researches on this subject. The same difficulties exist with respect to 
the supposed degeneration of cancer into fat. Nothing is more common 
than to find associated with cancer, a yellowish friable matter, more or 
less abundant, resembling cream in color or consistence, or presenting 
a briglit gamboge yellow tint. This, on examination, is found to consist 
of numerous granules, which disappear on the addition of ether, and 
refract light like globules of oil. AVhether these granules are element- 
ary nuclei and cells, or whether they are the result of the disintegration 
of cells previously formed, is unknown. — C] 

590. The third indication, to counteract the effect of morbid growths, 
is more commonly the object of treatment; but the means of fulfilling 
it fail more and more as the disease advances. The use of narcotics of 



DISORDERS OF MECHANISM. 361 

every description/ general and local, to soothe the pain and irritation, 
and of occasional local antiphlogistic measures to remove inflammation 
and congestion, is commonly admitted in palliation of malignant dis- 
ease ; but the importance of tonics and nutritive diet to counteract the 
increasing cachexy and emaciation, is not so generally regarded. Yet 
these have appeared to me to have considerable efficacy in supporting 
the constitution, and supplying it with strength against the enemy that 
is preying on its vitals. Preparations of iron, when borne, are the best 
tonics. The remarkable absence of fat, in the textures wasted by pro- 
longed cancerous disease, suggests the possible utility of cod-liver oil as 
a nutrient article. 



SECTION IX. 

DISORDERS OF MECHANISM. 

591. Many structural diseases arise, from changes in the mechanism 
of organs, which are not precisely implied in any of the preceding ele- 
ments. It is quite needless to enter into a detail of these alterations 
of mechanism; but to complete our key to the elements of disease it will 
suffice to cite a few examples. 

Hollow organs are liable to dilatation from an undue accumulation of 
matter within them. Thus the heart, arteries, and veins, the air-ceils of 
the lungs, portions of the intestinal tube, the bladder, &c, become dis- 
tended when there is an obstruction to the passage of their respective 
contents, or when the expulsive power by which they are contracted is 
weakened; and such distension, if long continued or frequently repeated, 
becomes a permanent dilatation. 

Parts may become overstretched and relaxed by a loss of natural cohe- 
sion or elasticity ; thus, ligaments, tendons, and fasciae become relaxed 
and ineffectual in binding together or connecting the parts to which they 
are attached. 

692. Contraction is the opposite of dilatation. It may constitute 
stricture, and lead to the partial or total obstruction of parts of the 
canals of the intestines, urinary and respiratory apparatus, vascular 
systems,' &c. The influence of contraction of the texture of organs and 
of serous membrane, we have several times had occasion to notice as 
the results of disease. 

593. Parts may be ruptured or lacerated, either from previous disease 
or from violence, and structural disease is the result. Thus, hollow organs, 

^ In this, and other painful complaints, the acquisition of an effectual and harmless ano- 
dyne agent, is an inestimable boon to suffering humanity ; and the discovery, by Professor 
Simpson, of the powerful ansesthetic influence of Chloroform, or terchloride of Formyle, 
promises to supply a most valuable addition to our materia medica. Hitherto, it has been 
used only (by inhalation of its vapor) to induce insensibility during painful operations, in 
the same manner as sulphuric ether (^ 128) ; but we may reasonably expect that an agent 
which, by its full influences, can destroy the most acute pains, may, by a moderate and more 
continued administration, permanently mitigate more constant sufferings. Probably, we 
may hereafter find this remedy available in the form of an anodyne smelUng-boUle. 



362 STRUCTURAL DISEASES. 

the heart, or arteries, the stomach, the gall-bladder, the urinary bladder, 
have been ruptured with speedily fatal results. Rupture of the valves of 
the heart, of portions of bloodvessels, of air-cells, &c., injures the 
mechanism of these parts and forms an element of structural disease. 

594. Displacements and compressions of organs are frequently the 
effect of tumors or effusions, as in the case of the tumor of ascites, or 
ovarian dropsy, or an enlarged liver, pushing up the heart and lungs, 
and variously compressing and displacing the abdominal viscera ; of an 
enlarged heart, or aneurism, displacing and compressing the lungs and 
air-tubes ; effusions in a pleural sac, compressing the lung of that side, 
and displacing the heart, mediastinum, diaphragm, liver, and the walls 
of the chest. 

595. Contortion of rigid parts is exemplified in rickets, mollities 
ossium, and rheumatic nodosities of the joints. Curvature of the spine, 
besides shortening the length of the trunk, disorders also the mechanism 
of respiration, by changing the position of the ribs; and when the dis- 
tortion is great, the function of the heart and great arteries, and of the 
abdominal viscera, may be likewise affected by it. 



363 



CHAPTER Y. 

THE CLASSIFICATION, SYMPTOMS, AND DISTINCTION OF DISEASES. 



SECTION I. 

NOSOLOGY. 

596. HAvma considered the causes of disease, their mode of opera- 
tion, the resulting effects on function and structure in the ultimate and 
proximate elements of disease, and the remedial influences which can be 
brought to remove or counteract these elements ; we have next to notice 
the manner in which these elements of disease affect the several parts 
and functions of the body, the symptoms which they induce, and the 
combination or forms which they present, as s]pecial diseases. In order 
thus to allot together in distinct divisions the wide domain of disease 
that has been displayed by general pathology, it is necessary to define 
special diseases ; that is, to designate their peculiarities of situation, 
kind, and phenomena, by short descriptions, and to group and sub- 
divide them in classes, orders, genera, and species. This classification 
and definition of diseases is usually implied by the word Nosology. 

597. Diseases may be classed in different ways. The first method 
attempted was a classification according to their most prominent phe- 
nomena, or symptoms. Of this kind was the system of Sauvage, who 
divided diseases into ten classes : Vitia, febres, phlegmasiw, spasmi^ 
anhelationes, debilitates, dolores, vesaniw, fluxus, cachexise. The classi- 
fications of Linnaeus, Vogel, and Sagar w^ere also of this kind, which 
may be termed artificial ; and Cullen's division was a strained simplifi- 
cation of the same description of arrangement, condensing all diseases 
into the four classes — pyrexise, neuroses, cachexise, and locales. 

The chief objection to this, which may be called symptomatic nosology, 
is, that it regards symptoms as the essence of diseases, whereas many 
symptoms are not essential, and those that more constantly occur are 
extremely variable, both in their kind and severity, and by no means 
uniformly correspond with the nature or with the amount of the real 
change of function and structure present. Hence, too, similar symp- 
toms, from the most diverse causes, are classed together, although they 
may require quite opposite plans of treatment ; whilst diseases that are 
really kindred in their nature, are wndely separated, because they differ 
in their symptoms. The artificial method of classification is admissible 



864 NOSOLOGY. 

« 

only as a provisional means of arranging subjects in a conventional 
way, until the true nature of these subjects is investigated ; when this 
is done, or even as it advances, the artificial method should give place 
to the natural one, which is not a mere glossary of names (or symp- 
toms), but in itself expresses the most important points of knowledge 
of the nature of the subject. 

598. The true foundation of a natural classification of diseases is in 
a correct pathology, or knowledge of the intimate nature of diseases ; 
but the subdivisions are conveniently determined by the chief seat of 
the disease, or by other of its more prominent characters. The classi- 
fication of Pinel approaches to this standard, although it is necessarily 
imperfect from the infant state of pathology at his period. He divided 
diseases into five classes: Fevers, inflammations, hemorrhages, neuroses, 
and organic affections. 

Pathology may be applied to the classification of diseases in two 
modes. In one, it is the first step in the arrangement, all diseases 
being distributed in classes expressive of the several pathological ele- 
ments aifecting the systems defined by general anatomy. Thus, ac- 
cording to the groups of pathological elements which we have reviewed, 
the classes might be : Diseases of the muscular system, those of the 
nervous system, of the secernent system, of the blood, of the vascular 
system, and of nutrition. The subdivision of these classes into orders 
would be determined by the individual pathological elements ; thus, 
diseases of the muscular system would be divided into those of irrita- 
bility and those of tonicity, with the generic subdivision according to 
excess, defect, or perversion ; and, lastly, the specific distinctions would 
be made according to the organ or locality affected. This arrangement 
is not suitable for clinical or practical purposes, because diseases are 
generally too compound to admit of being classified according to their 
elements : they commonly comprise several pathological elements, and 
the proportions of these elements vary with the progress of the case. 

599. The other mode of using pathology in nosology, is by making 
it subservient to establish those divisions or subdivisions in which the 
character of its elements affords an obvious and natural mean of distinc- 
tion, which may be useful in the diagnosis and treatment of disease, 
whilst the remaining divisions are derived from the situation or other 
circumstances of the disease. Thus, diseases maybe classed according 
to their chief locality, the organ or set of organs which they affect. 
Thus, as classes of disease, we may have, diseases of the organs of 
respiration; diseases of the organs of circulation ; of the apparatus of 
alimentation; of that of urinary excretion and of generation; of the 
nervous system; of the organs of locomotion ; of the skin; of the blood; 
and, lastly, general diseases, have no defined seat. The division of 
those classes into orders is founded on pathology; thus, each class com- 
prehends functional diseases, subdivided into diseases of irritability, 
tonicity, sensibility, &c., and secretion; and inflammatory and congestive 
diseases; and diseases of nutrition {structural). A farther division into 
genera and species is made according to the anatomy of the parts : thus, 
of the class, diseases of tlie organs of respiration; order, functional 
disorders; genus, irritability ; the species would bo spasm anii paralysis 



CLASSinCATIOX OP DISEASES. 365 

of the larynx^ of the hronchi^ kc. But in general diseases, the sub- 
divisions must be altogether pathological, or founded on causes or 
symptoms : thus, fevers are distinguished into inftammatorij, eruptive, 
adynamic^ or contagious, and malarious, or intermittent, and continued, 
as each of these modes of distinction becomes most available. 

This last classification, although it may be less pure and methodical 
than others, is the most useful in practice, because it most closely fol- 
lows nature; and, setting aside more minute and difficult distinctions, it 
leads to the seat and nature of the disease, and renders available those 
general principles in pathology and therapeutics which form the founda- 
tion of rational medicine. A chief recommendation of this kind of 
nosology, or arrangement of individual diseases, is, that whilst it in- 
cludes ail diseases hitherto distinguished, it points out others which 
may and do occur, but, for want of distinct pathological views and 
names, have been confounded with those more prominently defined. 

600. The definitions by which individual diseases are designated, 
may refer either to the pathological nature of the disease, or to its 
characteristic symptoms, or to both; and, in some instances, the causes 
or results of the disease form a characteristic part of its history. It 
should be remembered that the great purpose of nosology is to arrange 
and define diseases in such a manner that their true nature, with the 
chief points of affinity and diff'erence between each other, may be ex- 
pressed by the arrangement and definition ; and whether these points 
of affinity or diff'erence are most manifest in the causes, nature, or 
symptoms of the diseases, the arrangement and definition should duly 
regard them. Thus, besides its chief peculiar symptoms, the definition 
of a distinctly infectious disease, as scarlatina, should express its infec- 
tious character; that of a disease indubitably caused by marsh miasmata, 
as ague, should imply this fact ; whilst, both being classed as general 
diseases, and in the order fevers, the one of the genus eruptive, the 
other of the genus intermittent, much of the nature of the diseases, as 
well as of their distinguishing characters, will be set forth by this noso- 
logical arrangement. The farther that our knowledge of pathology is 
advanced, the more considerable a part will it form in our nosological 
systems; but, in the mean time, it is better to render our classification 
and definitions as useful as possible, by deriving them from all the most 
available sources of information, than to keep them imperfect and inap- 
plicable until science is sufficiently advanced to supply us with a system 
that is quite pure. 

As we do not enter upon specidl pathology, or the history of indi- 
vidual diseases, it is unnecessary to proceed into details of nosology. 
The foregoing remarks are intended merely to explain the objects of 
nosology, and to introduce the two associated subjects, semeiology and 
diagnosis. 



366 SEMEIOLOGT. 



SECTION II. 

SEMEIOLOGT AND DIAGNOSIS. 

601. SemeioJogy treats of signs,^ and in medicine, of the signs of 
disease. The word symptom, is commonly used in the same sense as 
sign; but, as its etymology implies,^ it is a more vague expression, 
signifying coincidence^ or co-occurrence^ rather than a direct or constant 
connection. It has been attempted by some writers (particularly 
French), to restrict the word symptom to the -phenomena manifested 
by present disease only ; but this is contrary to the usual custom by 
which we speak of precursory and consecutive symptoms^ symptoms of 
healthy kc. Again, some have confined the term symptom to the phe- 
nomena depending on vital properties, whilst those phenomena of dis- 
ease which are more directly physical, they call signs. This was the 
sense in which Laennec used these words, and others have followed his 
example. Although this acceptation of the words is not in strict ac- 
cordance with former usage, or with their etymology, yet it would be 
convenient for conventional use ; and, to render it more precise, it will 
be well to prefix the epithets vital and physical, as first suggested by 
Bayle, and partially adopted by Laennec. 

Let us, then, understand the word sign of disease generally to imply 
anything by which the presence of disease may be made known. A 
symptom is any phenomenon which becomes obvious in the course of 
disease : it may thus often prove to be a sign ; but many symptoms are 
of such uncertain connection with a particular disease, that they cannot 
be said to make known the presence of a disease ; and, therefore, they 
cannot be called signs. The more specific designation oi physical signs 
and vital symptoms will succeed better in attaching a distinct meaning 
to the different phenomena of disease ; and, by stating briefly the grounds 
of this distinction and the proper application of the terms, we may be 
able to point out the respective value of each class of phenomena to 
which they are properly applied. 

602. Physical signs are those physical properties of the body, or of 
a part of it, which are perceptible to any of the senses of the observer. 
Thus, the form, size, color, firmness or softness, weight, heat, and odor 
of the whole body, may be said to give physical signs or evidence of its 
condition, whether in health or in disease. So, also, the form, size, 
color, resistance, position, temperature, smell, and acoustic properties 
of a part of tlie body, aiford physical signs of its condition, whether in 
liealth or in disease. Thus, the appearance of an external disease, the 
feeling of a solid tumor, or of tlie fluctuation of liquid in the abdomen, 
listening to sounds produced l)y or in diseased internal parts, furnish 
us will) physical signs of the presence of disease. 

1 " Sif/n, tl.Jit by -wliicli niiytliing is known." — Johnson s DicliGnary. 

2 lviAvm3u.a, j'roni yyv, >vitli, an'l tcttto or tttox, to fall. 



SIGNS OF HEALTH AND DISEASE. 367 

The difference between the signs of health and the signs of disease 
is determined by our knowledge of what is usual in health ; and this 
knowledge may be derived (1) from general observation or experience 
of healthy standards, or (2) from anatomical and physiological know- 
ledge of what the phenomena of health ought to be ; or (3j from a par- 
ticular knowledge of the standard of health in any individual case. 

All of these healthy standards of comparison are available ; the first 
is less exact than the other two ; but it is often available for obvious 
disease. Thus, a jaundiced hue of the body, extreme pallor, or great 
emaciation, affords to the common observer physical signs of disease 
which cannot be mistaken. But slighter degrees of the same signs may 
become manifest only to those who, by previous acquaintance, know 
more exactly the standard of health in the individual, and can distinguish 
a change in color or in flesh from that standard. Again, in local dis- 
ease : a large tumor or swelling in a part is a sign of disease obvious to 
every one ; but a smaller or more deep-seated tumor may be discovered 
by those only who have an accurate knowledge of the healthy anatomy 
of the part, or by those who, by previous observation, have made them- 
selves familiar with the shape and feel of the part in health. 

603. Another standard available to distinguish the physical signs of 
disease from those of health is a comparison of parts that are naturally 
symmetrical. Thus, a slight swelling in one limb may be readily dis- 
covered by comparing it with the corresponding part of the opposite 
limb. A projection or contraction of one side of the chest may escape 
observation until the two sides are compared by inspection or by mea- 
surement, which will detect the difference between parts that are natu- 
rally alike. This standard of symmetrical comparison is applicable, 
not only to all external parts and organs of animal life, but also to 
some internal parts, which, although not strictly symmetrical, are so far 
equally distributed on the two sides as to give symmetrical properties 
to the exterior. Thus, the lungs, in health, fall so equally on both 
sides of the chest, that they give corresponding motion and acoustic 
properties to both; and percussion or respiration yields similar signs on 
both sides. So, when disease affects one side, it changes its physical 
signs, and their difference becomes obvious by comparison with the 
signs of the healthy side. A certain degree of uniformity also results 
from the position of the viscera in the abdomen, so that (making allow- 
ance for the greater bulk of the liver on the right side), any considerable 
difference in the shape or resistance of the two sides may be interpreted 
to be a sign of disease. 

604. For organs which are not symmetrically placed, previous know- 
ledge of their natural structure, position, and physical properties is 
necessary. Thus, we cannot know the physical signs of diseases of the 
heart and liver, without having a healthy standard to compare them 
with. This standard is soon supplied by the observation of the signs 
in health, and our knowledge of it may be much assisted by a familiar 
acquaintance with anatomy and physiology, which teach the healthy 
condition and functions. Thus, anatomy teaches us that the heart lies 
behind the lower half of the sternum and the adjoining parts of the 
cartilages of the left ribs from the third to the sixth ; and physiology 



368 SEMEIOLOGY. 

makes us acquainted witli its regular double sound heard in this region ; 
these furnish a healthy standard ; and when we compare it with a case 
in which the impulse of the heart is felt to beat over a much wider 
space, and the sounds are irregular, and masked by grating or blowing 
murmurs, we at once discern these phenomena to be signs of disease. 
Again, anatomy informs us that the liver in a healthy adult extends 
little, if at all, below the margins of the ribs on the right side ; and the 
knowledge of this fact points out as a sign of disease such dulness on 
percussion and resistance to pressure below these ribs as arise from the 
liver reaching much below its usual situation. The knowledge of the 
healthy mechanism and functions of the apparatus of respiration, circu- 
lation, digestion, and excretion is in many respects necessary to enable 
us to distiuD-uish the sio^ns of disease from those of health ; it will 
guide us to refer the signs to their true causes ; and it may often sug- 
gest the particular signs which may be expected to arise from a par- 
ticular lesion. 

605. Physical signs are phenomena taking place in the body, in ac- 
cordance with physical laws. It is, therefore, obvious that a knowledge 
of these laws, as well as of the mechanism of the body, will assist us 
to interpret these phenomena ; to explain of what they are signs, how 
they are caused, the variations which they may present, and the best 
mode of appreciating them. Thus, an aneurism of the arch of the aorta 
may be chiefly detected and studied through the physical signs which 
it produces. It forms a tumor under or near the top of the sternum, 
pulsating in a distinct manner, and with a peculiar sound ; this tumor 
may press on the air-tubes in such a way as to alter their shape, and, 
by partially obstructing the passage of the air through them, may also 
change the sound of breathing in a particular way ; by compressing the 
veins, it may also throw their current into unusual sonorous vibration ; 
or, by a more complete obstruction, it may cause the veins to swell in a 
remarkable degree above the tumor ; by its enlargement, the aneurism 
encroaches on the lungs, the walls of the chest, the muscles, nerves, 
bones, ligaments, &c., in such a way as to alter their physical properties 
and positions, and thus to produce various physical signs. Now, all 
these physical signs are phenomena produced in the altered mechanism, 
according to certain laws ; and it is plain that a knowledge of these 
laws must greatly assist us to understand the signs, and to trace them 
to their true causes. Nay, even the aneurismal tumor itself, in its pro- 
duction, increase, and intrinsic signs, can be rightly understood only 
througli a knowledge, of hydraulics and dynamics, in connection with 
the structure of the heart and arteries in health and disease. 

606. Vital symptoms are those phenomena which depend on vital 
properties of a part or parts of the body. Thus irritability, tonicity, 
sensibility, cxcito-motion, secretion, and the more complex functions re- 
sulting from combinations of these clementar}^ vital properties (§ 104), 
in a natural state, produce the symptoms of health ; in an altered state, 
constitute the symptoms of disease. Hence vital symptoms have also 
been called functional symptoms, and jjhysiological; but both these 
terms are objectionable, because both function and lohysiolorjy relate 



PHYSICAL SIGNS AND VITAL SYMPTOMS. 369 

likewise to physical properties ; and would, therefore, include physical 
signs. 

Vital symptoms are often less confined to a part than physical signs ; 
because vital properties of the whole system are in mutual connection ; 
thus the irritability of the heart spreads its influence throughout the 
vascular system ; the sensibility of one part affects the nervous centres, 
and may produce sympathetic symptoms in other parts (§ 156) ; dis- 
ordered secretion has effects on other parts (§§ 162-T, &c.) ; so that 
vital symptoms are often generally distributed throughout the body. 
For this reason they have been sometimes called general symptoms, to 
distinguish them from physical signs, which are chiefly local ; but this 
appellation is not exact, inasmuch as vital symptoms are sometimes 
entirely local ; as in the case of pain, spasm, &c. ; and we have already 
mentioned that physical signs are sometimes quite general throughout 
the body, as those of the yellowness of the whole surface in jaundice, 
the swelling of the body in dropsy, &c. 

Vital symptoms are sometimes called rational^ because (I presume) 
their connection with their cause is rather a matter of inference than of 
direct observation ; but this is the most absurd term of all ; for observa- 
tion is necessary to teach us the value as much of symptoms as of phy- 
sical signs; and physical signs are of little use without a proper exercise 
of reason upon them. 

60T. Vital symptoms maybe exemplified in pain, uneasiness, altered 
and impaired sensations, which arise respectively from exalted, per- 
verted, or defective sensibility (§§ 125-136) in spasm and paralysis, 
which proceed from excessive or defective contractility (§§ 110-118), 
or excito-motory power (§§ 139-154) ; in cough, which is caused by 
irritation, or undue excitability of the excito-motory nerves of the air- 
passages, and muscles of expiration ; in vomiting, which depends on 
irritation or undue excitability of the stomach, and the excito-motory 
nerves sympathetically allied with it ; in dyspnoea, which arises from a 
feeling of want of breath (§ 234) ; in fever, which comprises an accel- 
erated pulse, hot skin, diminished secretions, &c. (§ 437). 

Symptoms may farther be found in the state of the different bodily 
functions in which vital properties are concerned. Thus, the state of 
the pulse is an important source of symptoms; a frequent or a slow pulse 
indicates an increased or deficient excitement or irritability of the heart 
(§§ 113, 117) ; a strong or weak pulse implies an increased or diminished 
strength of the heart's contractions (§§ 112, 116). A hard or sharp 
pulse is, in part, dependent on an increased tonicity of the arteries 
(§ 121) ; whilst a soft, compressible, or liquid pulse, depends on a dimi- 
nution of this property (§ 123). Irregularity in the rhythm of the pulse 
arises from an alteration in the vital property of irritability in the heart, 
commonly connected with loss of strength. These various conditions 
of the pulse are sometimes the result of various diseases directly affect- 
ing the vital properties of the heart and arteries themselves; but more 
commonly, they are induced by diseases of other parts sympathetically, 
or through the blood influencing these organs, as in inflammatory fever 
(§ 437). Thus, in diseases of the heart and arteries, the pulse has more 
24 



370 SEMEIOLOGY. 

of the character of a physical sign ; whilst in other disorders, it is rather 
a vital symptom, depending on farther vital properties. 

The state of the skin is another source of symptoms, chiefly con- 
nected with the vital properties of the superficial vessels, and secernent 
apparatus, and of the general circulation. Thus, the heat and dryness 
of the skin in fever, arise from accelerated circulation with diminished 
perspiration. When the skin is cold, the circulation is weak ; when 
warm, it is active ; and the occasional occurrence of perspiration in both 
these conditions, shows that another vital property, that of secretion, 
is concerned in causing the symptoms dryness and moisture of the skin. 
The signs furnished by the skin are physical, so far as regards the con- 
dition of the skin itself; but they are vital symptoms in relation to the 
state of the circulation, of distant organs, or of the system at large. 

Many important symptoms may be derived from the appearances of 
the tongue. These appearances, when arising from primary disease in 
the tongue itself, may be considered as physical signs of its condition. 
Thus, when the tongue is inflamed, it is first red and swollen, and after- 
wards becomes covered with a film or fur, which, separating in patches, 
leaves the surface red, and smoother than before. But in a great many 
diseases, the tongue becomes red, svfollen, furred, or brown and dry, 
from causes acting through the system ; and these secondary affections 
of the tongue constitute symptoms of these diseases. The connection 
between febrile and other general diseases, and the appearances which 
they produce in the tongue, is not well understood ; but it probably de- 
pends on changes in the secretion of the mucous membrane covering 
the tongue and adjoining parts. 

The alvine excretions furnish symptoiiis of great importance in various 
diseases. When excessive in quantity, liquidity, and frequency, they 
constitute diarrhoea, which may be primary — that is, a disease in itself 
(§ 374) ; or secondary, and, therefore, a symptom of disease, as in cho- 
lera and mucous enteritis. As a symptom, it presents farther varieties 
in its character, whether feculent, bilious, mucous, watery, &c. ; and 
these varieties indicating respectively accumulation of feces, or exces- 
sive secretion of bile, or mucus, or watery fluid in the intestines. The 
opposite condition, that of costiveness, is also a disease itself, and an 
important symptom in many diseases, indicating defective peristaltic 
action, defective secretions, or both, in the intestinal tube. The quality 
of the evacuation supplies symptoms in regard to color, shape, odor, 
&c., which often lead to a knowledge of the nature of disorder in the 
alimentary canal or in the system. Thus clay-colored feces indicate 
defective secretion from the liver ; those very dark in color may denote 
the presence of diseased bile, or altered blood ; vermicular motions may 
indicate stricture, or contraction of the intestine, and so forth. 

The urinary excretion is a valuable source of symptoms, not only of 
diseases of the parts connected with it, but of disorders of other organs, 
and of the whole system. Being the chief emunctory through which 
foreign effete and superfluous matters are eliminated from the blood 
(§ 2r>4), it is continually exhibiting changes in quantity and quality, in 
color and specific gravity, in its sediments, and in the effect on it of 
difierent chemical reagents. All these changes furnish symptoms of 



PHYSICAL SIGNS AND VITAL SYMPTOMS. 371 

disease, several of wliicli have been already noticed in connection with 
various pathological elements ( §§ 167, 176, 249, 254, 255, 257, 260, 
309, 384, 385, 448, &c.). 

608. The foregoing examples of sources of symptoms are given 
merely to illustrate where and how symptoms are to be sought for ; to 
complete the list, it would be necessary to notice every function of every 
part of the body, and the symptoms which they furnish, which would fill 
a considerable volume. 

As a knowledge of the mechanism of organs, in health and in dis- 
ease, and of the physical laws which operate in them, is the best aid 
to the study of physical signs, so an accurate acquaintance with the 
structure and functions of the healthy and diseased body, and with the 
vital laws which influence them, is the best guide to the knowledge and 
explanation of vital symptoms. These symptoms are often obscure 
and unintelligible, because physiology and pathology are imperfect ; 
but, in proportion as these sciences are advanced, their application to 
semeiology and diagnosis will be more complete. In the mean time, 
much of our knowledge of symptoms rests chiefly on mere experience; 
and, until the results of experience can be arranged in a more scientific 
manner, they may be parcelled numerically^ in order to approach their 
laws by empirical means. But to render this statistical or numerical 
method of studying symptoms at all safe, it is necessary that the 
number of observations should be very large, that they should be 
applied to similar cases, and that the majorities which establish the 
rule, should very greatly preponderate over the exceptions. 

609. Physical signs and vital symptoms respectively have their value 
in making known the nature and extent of disease. Physical signs 
are more certain, because they appeal more directly from the seat of 
disease to the senses; depending on simpler and more constant causes, 
physical properties, they are more constant and less subject to varia- 
tion than vital symptoms, which result from more complex, and, there- 
fore, more variable vital properties. Thus, of the signs of inflamma- 
tion, the redness, heat, and swelling are physical signs, and more cer- 
tainly prove the existence of inflammation than does pain, which is a 
symptom depending on the vital property, sensibility, and which may 
be present where inflammation does not exist (§ 136), and may fail to 
occur when inflammation is present (§ 433). The physical signs of a 
structural disease in the lungs or heart, are better evidence of its 
existence, and of its nature, than cough, dyspnoea, pain, palpitation, 
&c. ; because we know that these symptoms may arise from merely 
nervous or other causes, without the presence of any alteration of 
structure. Yet vital symptoms, although less sure and constant than 
physical signs, are often more delicate, being present before physical 
changes become appreciable ; and when they coexist with visible signs, 
they indicate the nature and amount of disorder of the vital properties 
of the part, and of the whole system. Thus feelings of chilliness and 
discomfort, which usher in the fever accompanying tonsillitis, are 
sometimes present before the throat exhibits the physical signs of 
inflammation. A slight cough is often present in the early stage of 
phthisis, before the physical signs of tubercles can be distinguished. 



872 



SEMEIOLOGY, 



Crepitation heard in the posterior regions of the chest is a physical 
sign of engorgement of the lung, with liquid in the minute tubes ; but 
we must refer to the vital symptoms to determine whether the engorge- 
ment is inflammatory, or only congestive. The physical signs of con- 
solidation of the lung, and of valvular disease of the heart, are very 
distinct; but, in order to determine whether these affections have arisen 
from present or recent inflammation, or are the results of old disease, 
it is necessary to consult the vital symptoms ; and this determination 
is of great importance to the prognosis and treatment. 

In short, it is obvious that both classes of signs ought to be carefully 
taken into account ; and the more fully the physical and vital pro- 
perties which constitute them are understood, the more available will 
signs and symptoms be, to instruct us as to the nature and treatment 
of disease. 

610. Besides into physical and vital, various divisions of symptoms 
have been made; but they are of little real utility, and it is unnecessary 
to do more than enumerate them. Symptoms are locals or general, or 
constitutional, according to whether they are confined to the diseased 
part, or affect more or less the whole system. Symptoms are idiopathic, 
when directly proceeding from a primary disease; they are sympathetic, 
or secondary, when arising from secondary disorders, or those produced 
by the primary disease. Premonitory or precursory symptoms are 
those which precede the full development of disease, and commonly 
result from the first operation of its cause ; hence they are called symp- 
tomata causae. Commemorative symptoms are those developed in the 
previous history of the disease. Anamnestic are those which relate 
to the previous state of health. Signs have been divided into objective, 
those which present themselves to the scrutiny of the practitioner; and 
the subjective, those described by the patient himself. The objective 
have been farther divided into the active, or dynamical, those that re- 
quire some action, motion, or manipulation to discover them ; and the 
jyassive, or statical, those that are obvious without such action. Symp- 
toms are designated by the epithets diagnostic, prognostic, and thera- 
peutic, when they are specially applicable respectively to the distinction, 
the determination of the event, and the suggestion of the treatment 
of disease. Symptoms are positive, when they consist of phenomena 
actually present ; negative, when they consist in the absence of phe- 
nomena. Of diagnostic symptoms, those are called pathognomonic, or 
pat! tog no Stic, which are peculiar to one disease. A single symptom or 
sign is rarely, if ever, pathognomonic; but two or three taken together 
often are so. 



[Some of the more important general signs of disease will be now 
enumerated, in the study of semciology, several methods have been 
pursued. The one most useful, and most generally practical is, pro- 
bably, that compounded of the topographical method, in which the 
symptoms presented by each portion of the body are treated of suc- 
cessively ; — and the ph.yslological mctliod, which studies, each appa- 
ratus of organs and functions, ap[)roximating those which offer most 
relation and analogy, thus grouping, in a natural way, the various 



DECUBITUS. 373 

symptoms whicli the case presents. Accordingly, after an exposition 
of the signs derived from the external exploration of the patient — 
commencing with the body as a whole, with reference to attitude, con- 
figuration, and volume, and then passing to the consideration of the 
signs furnished by each region of the body respectively — we shall 
detail the symptoms and signs supplied by each of the great functions 
— as the nervous, respiratory, circulatory, &c. (§ 615.) 

I. The symptoms presented by the exterior of the body, are of the 
greatest importance. By a first glance at the general aspect of the 
patient — a coup (Toeil d' ensemble — the experienced physician, of quick 
perception and tact, derives most valuable information, and often re- 
cognizes the nature of the disease, and ascertains the actual condition 
of the patient. Many diseases, indeed, have their own special phy- 
siognomy, which is readily recognized by the initiated. "Medical 
physiognomy," it has been well observed, "is, in many diseases, a 
source of diagnosis which seldom fails the practitioner who is intimately 
versed in it ; and we believe that much of that exquisite tact in the 
discrimination of disease which distinguishes some practitioners, and 
which others can never attain, depends on the vivid perceptions of an 
eye and ear habitually familiar with the lineaments, the tone, and the 
gestures of disease."^ 

The position and movements of the body and limbs, and the consti- 
tutional peculiarities and physiognomy of the patient, are of importance 
in a correct diagnosis. 

The attitude varies more or less in disease. There may be an un- 
usual degree of languor, as in the invasion of most acute diseases, or 
in the course of chronic ones ; or the bearing may be unnaturally bold 
and assured, as in insanity or acute delirium. There are some diseases 
which may be at once recognized from the position of the patient ; as 
catalepsy, from general immobility ; chorea, from irregular and perpe- 
tual movement; hemiplegia, from distortion of the features, and altered 
position and impaired motion of the limbs ; and tetanus, from the con- 
dition of the trunk. 

The signs furnished by decubitus, or decumbenee — the posture of 
lying — are often of value. In health, the position in sleep is on either 
side, perhaps oftener on the right, the body and limbs semiflexed, and 
the head bent towards the chest. A departure from healthy decum- 
benee is noticeable in most diseases. When it is constantly dorsal, it 
is a token of extreme debility ; of loss of motion, or of some afi'ection 
in which movement is accompanied with severe pain. Hence we meet 
with it in all diseases attended with great prostration ; in cerebral 
apoplexy, and in organic diseases of the brain and spinal marrow ; in 
acute peritonitis ; and, in general, articular rheumatism. The decum- 
benee is prone in gastric, intestinal, hepatic, and renal colic, though 
generally not lasting ; the patient frequently changing his position. 
It is lateral in certain affections of the chest, as pleurisy or pneumonia, 
or rather, in certain stages of those affections. No general rule can be 
given as to the position in bed of patients suffering under inflammation 

^ British and Foreign Medical EeTiew, July, 1841, p. 108. 



374 SEMEIOLOGY. 

of the pleura or lung. It is very variable ; sometimes on the affected, 
sometimes on the sound side; but, more frequently, if the effusion or 
hepatization be considerable, on the back. In double pleurisy or pneu- 
monia, it is probably always dorsal. In pulmonary tuberculosis, where 
one lung only is affected, the patient lies by preference on the diseased 
side. 

The sitting posture is generally assumed in certain affections of the 
thoracic viscera, which interfere with respiration, and cause orthopnoea 
— diseases of the heart, and arch of the aorta, acute phthisis, pneumo- 
thorax, hydrothorax, emphysema of the lungs, nervous asthma, etc. 
In this position, the body is usually inclined forwards, with the elbows 
resting on the knees; or some firm object is grasped by the hands, to 
fix the shoulders, and allow the respiratory muscles to act to greater 
advantage. In some affections of the abdomen, in which the cavity of 
the chest is invaded, and respiration impeded, the patient is obliged to 
be propped up in bed, or maintain the sitting position. 

In laryngeal and tracheal disease, or where these organs are com- 
pressed by a tumor, the head is usually thrown back, whether the atti- 
tude be that of standing, sitting, or lying. 

Persistence in the same position is usually a symptom of organic 
disease of the brain, or of idiocy. 

Restlessness, jactitation, or constant change of position, occurs at 
the invasion of acute inflammations, and the idiopathic fevers, and in 
many of the affections of children ; and frequently accompanies deli- 
rium and acute mania. 

The volume of the body may be augmented or diminished. A slight 
and transient increase of size occurs in the commencement of inflam- 
matory affections, and marked general tumidity of the body at the 
invasion of the exanthemata. An accumulation of fat is rarely a sign 
of disease, but may, when excessive, constitute a disease in itself — ■ 
'polysarcia. General enlargement of the body may proceed from ana- 
sarca^ or dropsy of the cellular tissue, or from cellular emphysema, 
caused by a penetrating wound of the chest. Emphysema may be 
distinguished from anasarca by its not pitting on pressure; by its 
elastic feel, and by the sensation of crepitation which it gives. AVhen 
the cellular infiltration is partial, it is termed cedema. CEdematous 
swelling may be more easily recognized when the disposition of the 
skin allows us to pinch it between the fingers. Incipient oedema may 
be often thus distinguished in patients confined to their beds, in the 
internal surface of the thighs (Chomel). In those who are up, oedema 
first shows itself around the malleoli, particularly towards evening. 

Diminution in the size of the body is a frequent phenomenon in 
disease. It may occur with great rapidity, and to a considerable 
degree after excessive alvine discharges, as in serous diarrhoea, and 
Asiatic cholera. It is said to take place, in the same manner, after 
one or two paroxysms of malignant intermittent. It generally occurs 
more slowly, constituting emaciation. Emaciation is a much more fre- 
quent consequence of disease than obesity. It attends most chronic 
diseases; and is often among the first symptoms of phthisis. The 
emaciation of special parts of the body is observed in some maladies. 



THE PHYSIOGXOMY. 3 



( D 



In disease of the liver and spleen, the face and extremities first waste ; 
in tubercular phthisis, the upper extremities and clavicular regions. 

II. The signs furnished by the head, face, and neck present nume- 
rous points of value. 

The head is bent to one side in convulsions, hemiplegia, torticollis, 
dislocation of the cervical vertebris, cervical glandular swellings, and 
large cicatrices of the neck, following burns. In vertebral malforma- 
tion, it is bent forward. It is bent backwards in diseases accompanied 
with dyspnoea ; as croup, laryngismus stridulus, suffocative catarrh, 
etc. ; as well as in tetanus, and spinal meningitis of the cervical portion 
of the cord. The size of the cranium is increased in chronic hydro- 
cephalus, and hypertrophy of the brain. The hairy scalp becomes 
cedematous in erysipelas, with extreme sensibility on pressure. It is 
sometimes enormously swollen in smallpox. 

The jpliysiognomy presents numerous shades of expression in the sick. 
It may appear sad, dejected, uneasy, terrified, indifferent, or attentive ; 
sometimes smilino^, at others menacincr or wanderins:, without there 
being any circumstance to account for these modifications of the fea- 
tures; which, consequently, should be classed among morbid pheno- 
mena (Chomel). Among the changes of countenance noticeable in dis- 
ease, are the following: Th-Q fades stupida, distinguished by the great 
dulness of expression, particularly of the eyes, the patient appearing 
as if intoxicated. This is the physiognomy of a patient with typhoid 
fever. The fades vultuosa, characterized by fulness and redness of 
the face, prominence of the eyes, injection of the conjunctiva, disten- 
sion of the eyelids and lips. It is met with in cardiac hypertrophy, 
and in cerebral congestion. The pinched countenance presents the 
opposite conditions, the face being apparently diminished in size from 
contraction of the features, and of a pale or livid hue. It is seen in 
acute peritonitis, and in healthy persons who have been long exposed 
to severe cold. The fades hippGcratica is thus described by Hippocra- 
tes : The nose is sharp, the eyebrows knitted, the eyes hollow and 
sunken, the ears cold, contracted, and thin, and the lobes shrivelled ; 
the skin about the forehead is hard, tense, and dry ; and the face pale, 
or of a greenish, livid, or leaden hue. It occurs in chronic disease 
immediately before death, and in acute disease which has been un- 
usually prolonged. 

Dr. Siebert distinguishes six groups of physiognomical rugse. The 
R. Transversse^ situate in the forehead, formed by the frontal muscle, 
express excessive pain arising externally. The R. ocidofrontales^ ex- 
tending from the forehead vertically to the root of the nose, express 
distress, anxiety, anguish, and severe internal pain. They also indicate 
in acute diseases an imperfect or false crisis, an impending efflorescence, 
and often a fatal termination. In severe headache, both the classes of 
rugae just mentioned are observed. "When the former join the latter 
abruptly in a disease, paralysis is impending or commencing. The 
linea oculo-zygomatica (of Jadelot), extending from the inner angle of 
the eye somewhat below the cheek-bone, indicates in children a cere- 
bral or nervous affection ; in adults, disorder or abuse of the genera- 



376 SEMEIOLOGY. 

tive organs. The Tinea nasalis of Jadelot and De Salle (the Rhinal- 
linea orbicularis of K. H. Baumgartner) begins at the upper border of 
the ala nasi, and extends more or less curved to the outer margin of 
the orbicularis oris. It is strongly marked in phthisis and atrophy. 
The inferior portion (linea hucealis) indicates gastric disease ; the upper 
portion (the proper linea nasalis)^ marks an affection of the upper part 
of the intestinal canal. Occurring conjointly with retraction of the 
cheek and with the L. oculo-zygomatica, the eyes being fixed and the 
complexion wan, it is a certain indication, according to Pieper, of 
worms. The L. lahialis extends from the angle of the mouth, and is 
lost in the lower part of the face. In children, it generally marks a 
thoracic affection, which renders the respiration laborious or painful. 
The L. collateralis nasi passes downwards in a semicircular direction 
towards the chin, and externally to the linea nasalis^ hucealis, and la- 
hialis. It generally indicates chronic and obstinate disease of the 
thoracic or abdominal viscera.^ 

Many of the specific forms of disease have their specific physiog- 
nomy. Children of a scrofulous constitution have either a delicate 
velvety skin, brown complexion, dark hair, with dark and brilliant eyes, 
and long lashes, with the lineaments of the face finely drawn and ex- 
pressive ; or, a fair complexion, thick and swollen nose, broad chin, 
irregular teeth, late developed, and early becoming yellow and carious, 
with inflammation of the Meibomian glands, scrofulous ophthalmia, in- 
tolerance of light, eruptions on the head, nose, and lips, and enlarged 
cervical glands. 

Oedema of the face and eyelids is sometimes met with in anaemia, but 
very frequently is symptomatic of albuminuria. 

Transient general redness, or flushing of the face, is common in wo- 
men suffering from menstrual irregularity, and at the critical period 
of life. The bright circumscribed redness of the makr regions, with 
paleness of the rest of the face, known as the "hectic flush," occurs in 
wasting chronic affections, and particularly in phthisis pulmonalis. 
When it is limited to one cheek, the corresponding lung has been 
thought to be the affected one. This certainly is by no means general ; 
but Dr. Stills mentions a case observed by him. The same opinion 
has been entertained with regard to the livid red patches in the same 
region in acute pneumonia ; but the researches of GrisoUe do not coun- 
tenance it. 

Paleness of the face happens in the cold stage of fevers, and acute 
inflammations ; in the hemorrhages ; in chronic diseases, particularly 
Bright's disease ; and in convalescence. The complexion of persons 
long deprived of a due amount of light, is unusually pale. The hue of 
the complexion of anemic patients is that of imperfectly bleached wax, 
or of a dingy white with a shade of green. A general yellow tint of 
the face is characteristic of jaundice. Sometimes, in slight hepatic de- 
rangement, the yellowness is limited to the labial commissures and alse 
nasi. A citron tint is constant in cancerous affections ; and a peculiar 
dingy light straw-color hue is met with in the inhabitants of malarious 

' Tcclmitt dor Mediciiiisehcii Diasuostik. B. and F. Medical Review, vol. xx. 



FORM OF THE CHEST. 877 

districts. A bluish hue of the face, and skin generally, is indicative of 
impeded venous circulation ; it is met with in asphyxia, from whatever 
cause ; in Asiatic cholera ; in typhus fever ; and particularly in cya- 
nosis (§ 238), and hence is often called the cyanotic hue. It partially 
disappears on pressure to return slowly. A permanent and deeper dis- 
coloration, amounting to slate color, is met with in persons who have 
been long subjected to the internal administration of nitrate of silver. 
It is indelible. 

Perpetual motion of the eyelids is noticed in some cases of mania and 
idiocy. In adynamic fevers, they are sluggish and heavy. In photo- 
phobia, they resist any attempt to open them. They remain open 
when the portio dura has been injured, in consequence of paralysis of 
the orbicularis. When there is lesion of the third pair of nerves, the 
upper lid is paralyzed. JEpiijJiora, or the flowing of the tears over the 
cheek, is caused by obstruction of the lachrymal duct ; it occurs in the 
initial stage of ophthalmia, and in some neuralgic affections of the eye ; 
and may be produced by the presence of a foreign body. 

The nostrils dilate forcibly and rapidly in difficult respiration. Itch- 
ing of the nostrils in children, is commonly regarded as a sign of intes- 
tinal worms. 

III. The throat becomes enlarged in some anginose affections, in the 
first months of pregnancy, and at the approach of puberty in the female. 
The carotid arteries pulsate violently in acute mania, cerebral inflam- 
mation, hypertrophy of the heart with dilatation of the right ventricle, 
in anaemia, and sometimes in typhoid fever. Habitual fulness of the 
jugular veins occurs in connection with some impediment to the circu- 
lation. Pulsation of the veins of the neck, and particularly of the 
jugular — called the venous pulse — is caused, according to the researches 
of Dr. Beau, by contraction of the right auriculo-ventricular orifice — 
whilst by others it is attributed to patency of the tricuspid valves. 
Mr. Sibson has judiciously analyzed the influence of the heart's action, 
and of respiration on jugular pulsation.^ . The mere existence of such" 
pulsation, he concludes, is anything but an indication of disease, either 
in the pulmonary valves or elsewhere. In diseases attended with im- 
peded flow of blood through the lungs and heart, the jugular veins 
contain more blood, and their pulsations are visible; but when the 
impediment is extreme, the veins are in a state of constant distension, 
and no pulsation is visible. The pulsation of the arteria innominata — 
which lies in front and rather to the right of the trachea, just above 
the sternum — is seen in aortic regurgitation. Various circumscribed 
swellings are noticed about the throat and neck, which are due to 
glandular enlargements ; as the thyroid gland, anteriorly and inferiorly, 
constituting goitre ; the parotid gland in the lateral superior region ; 
scrofulous lymphatic glands in the same situation ; and the maxillary 
glands beneath the lower maxillary. 

IV. Various deviations from the natural configuration of the chest 

1 Transactious of the Proviucial Medical and Surgical Association, vol. xii. p. 307. 



378 SEMEIOLOGY. 

may depend on malformation of the spinal column, natural or acquired. 
But independent of deformity from this cause, the thorax may present 
certain modifications in form of semeiological value. A healthy well- 
formed chest is nearly symmetrical, the two sides corresponding in 
shape and size ; but, though there is no visible inequality of size, the 
semicircular measurement of the right side of the chest, at the base of 
the lung, exceeds, in adult persons, that of the left ; a condition due 
probably to the influence of excess of muscular exertion on the right 
side ; for Dr. Walshe states, that in left-handed persons the left side 
sometimes measures more, or more frequently the same as the right. 
It is in form a cone, with its narrow end uppermost ; its transverse 
diameter is evidently greater than its posterior ; the post-clavicular 
regions are slightly depressed ; the lower sternal region is concave in 
proportion to the development of the individual ; the infra-clavicular 
regions are gently convex ; the intercostal spaces are visible in inspira- 
tion, and respiration, except in very fat persons ; the lateral portions of 
the chest are equidistant from the median line ; so also the nipples, 
which should be both on the same line ; there should be neither anterior, 
posterior, nor lateral deviation of the spinal column ; and the vertebral 
sulcus, moderately convex from above downwards, is more or less deep 
as the subject is fat or lean.^ But it is common to meet with certain 
deviations in form, congenital and acquired, perfectly compatible with 
health. General prominence or expansion of one side of the thorax is 
usually caused by a large pleuritic effusion. It is most common on the 
left side. Local expansion, or bulging, is a consequence of several 
pathological conditions. When its seat corresponds to the base of 
either lung, it is caused by a gravitating pleuritic effusion ; when situ- 
ated at the anterior superior parts of the chest, by emphysema; when 
in the right hypochondrium, by enlargement of the liver ; and when in 
the prsecordial region, by effusion into the pericardium, or by hyper- 
trophy of the heart. In aneurism of the ascending aorta, when ad- 
vanced, a tumor is visible about the junction of the third rib with the 
right side of the sternum ; whilst aneurism of the descending aorta 
makes its appearance between the base of the scapula and the spine. 
According to Dr. Chambers, one of the earliest physical signs of 
phthisis is a slight bulging of the anterior and superior regions of the 
chest. 

lletraction of one side of the chest, most usually the left, is met with 
at the period of absorption of general pleuritic effusion. Long-con- 
tinued pressure having reduced the volume of the lung, when the 
effused fluid — the compressing material — has been removed, the lung 
not recovering its original size, the chest yields to atmospheric pressure. 

Df'prcHHion, or local retraction, is met with at the period of absorption 
of circumscriljcd pleuritic effusion, and in pulmonary tuberculosis. 
Flattening and even depression of the infra-clavicular, post-clavicular, 
and upper scapular regions, occur in many cases of phthisis. 

By iMSpcction of the chest, the mode of respiration in the patient is 
ascertained. The number of respirations in a healthy male adult 

' Williams and Cljmcr, Diseases of llespiratory Organs, p. 24. 



FORM OE THE CHEST. 379 

generally ranges about twenty in a minute. It is more in females and 
in children. The act of breathing is accompanied, in health, by regular 
motions of expansion and elevation of the chest. These are increased 
in spasmodic asthma, and in all affections where dyspnoea is a prominent 
symptom. They are diminished, where there is an instinctive avoidance 
of pain, as in pleurisy and pleurodynia ; in paralysis of the respiratory 
muscles ; and when there is a material obstacle in the condition of the 
pleura or lung, as pneumonia, emphysema, pneumothorax, phthisis, &c. 
They are jerking when there is irregularity of muscular efforts, as in 
spasmodic asthma, obstructive diseases of the larynx and trachea, and 
pleurodynia. Respiration is quick when the movements of inspiration 
and expiration are performed with more than natural rapidity ; it is 
slow when the contrary condition obtains. In natural breathing, the 
diaphragm concurs. When this muscle remains at rest, in abdominal 
inflammations and diaphragmatic pleurisy, and the act of inspiration 
and respiration is chiefly performed by the ribs, the respiration is said 
to be costal, or high. When, on the other hand, the action of the ribs 
is diminished, and that of the diaphragm becomes increased, causing 
the rise and fall of the abdomen, the respiration is called abdominal. 

V. The abdomen, in health, is firm and pliant, moderately resonant, 
and varies in size in different individuals. In women who have borne 
children, and in both sexes where there has been abdominal distension, 
from ascites or other causes, white lineal marks, resembling cicatrices, 
will be found in the hypogastric region. In pregnancy, a brownish 
discoloration, situated on the median line, and extending from the pubis 
to the umbilicus, is often visible. 

The volume of the abdomen may be increased generally or partially. 
When general, it is owing to the presence of fluid in the cavity of the 
peritoneum, or to gaseous distension of the intestines. When the dis- 
tension from this latter cause is moderate, it is called meteorism; when 
excessive, tympanites. Different degrees of resonance accompany 
these symptoms; and the abdomen is elastic and resisting to the touch. 
They occur in adynamic diseases, peritonitis, intestinal obstruction, 
hysteria, &c. Local or regional enlargement of the abdomen takes 
place in the hypochondriac regions in diseases of the liver and spleen ; 
in the epigastrium, in hysteria and cancer of the stomach ; in the hypo- 
gastrium, in distension of the bladder, ovarian tumors, fecal accumula- 
tion, and the various varieties of abdominal tumors. 

Diminution in the size of the abdomen happens in most chronic dis- 
eases, unless accompanied by ascites, or there exists an abdominal tumor. 
In chronic dysentery, there is extreme retraction of the parietes ; and also 
in lead colic, in which the muscles are exceedingly hard and unyielding. 

VI. The external exploration of the gejiital organs in the two sexes 
furnishes several important symptoms. The penis is enlarged in child- 
ren suffering from vesical calculus, and who are addicted to mastur- 
bation. A cartilaginous hardness of the corpora cavernosa is said to 
occur in those who practice onanism. Retraction of the testicles happens 
in renal calculus. The scrotum is distended in hydrocele, hematocele, 



380 SEMEIOLOGY. 

and sarcocele. The labia majora are enlarged in general dropsy, and 
in certain local affections. 

VII. The extremities become immovable in paralysis, and contracted 
and rigid in softening of the brain, and in other organic diseases of that 
organ. They become oedematous when their chief vessels and nerves 
are pressed upon, and their circulation embarrassed. The articulations 
become swollen in rheumatism, hydrarthrosis, white swelling, &c. The 
limbs are diminished in size in paralysis (§ 534). 

We shall now proceed to consider the semeiology of the various func- 
tions. 

VIII. The signs furnished by the nervous system in disease are of 
great value. We shall begin with the modifications of general sensi- 
bility or common sensation (§§ 132, 133). 

Sensation is morbidly augmented in acute inflammatory affections of 
the brain and spinal marrow ; in the idiopathic fevers in hysteria ; and 
the so-called magnetic condition. Pain is at once an exaltation and 
perversion of sensibility, and is better understood than defined. There 
are several varieties of pain: 1. Tensive, with a feeling of distension, 
and is felt whenever parts are put on the stretch. It occurs especially 
in phlegmonous inflammation, and is generally accompanied with throb- 
bing. 2. Dull, or heavy, when accompanied by a feeling of weight ; it 
is experienced when there is enlargement of some of the viscera, an 
internal tumor, or effusion into the serous cavities. It is felt in the loins 
previously to menstrual and hemorrhoidal discharges. 3. Smarting, 
when the skin has been deprived of its cuticle ; or when some irritant 
has been applied to the unprotected skin. 4. Lancinating, character- 
ized by sharp, pungent, transient darting ; and occurs in cancer and 
^neuralgia. 5. Boring, resembling the sensation which a wimble or screw 
would produce in entering and turning on itself in the suffering part ; 
and accompanies constitutional syphilis, rheumatism, gout, inflammation 
of the periosteum, &c. 6. Burning, felt in burns and scalds, and in 
anthrax, and in gangrenous erysipelas. 7. Contusive, similar to that 
felt after extensive bruises, and is a constant prodromic phenomenon in 
acute diseases. 8. Tearing, ov pungent, Gom^dL^Qd to the sensation pro- 
duced by opening the lips of a wound ; 9, and finally, pain may be spe- 
cial in its character, as that experienced in hemicrania ; during labor, 
or an amputation; or from a blow upon a superficial nerve, as the cubital, 
at the elbow. Itclii7ig is a peculiar exaltation and modification of sen- 
sation, seated in the skin, occurring principally in cutaneous affections. 
Forr)ii(;ation is another perversion of the sensibility of the skin, and is 
so called from its resemblance to the feeling produced by the crawling 
of iriiiuinerable ants over the body. 

Common sensibility may be dirainished or abolished, the latter con- 
stituting anuesthesia. Diminution or loss of sensibility may be general 
or local ; it may or may not be accompanied by diminution or loss of 
motion ; and it may be organic or functional. 

The special senses may be exalted, impaired, or perverted. Exaltation, 
of vision occurs in ophthalmia and inflammation of the brain and its me- 



SENSATION — MOTILITY. 881 

ringes, and some nervous affections. This sense is diminished in many 
diseases, and totally abolished in some affections of the eye and brain. 
It is variously perverted in a number of maladies. Objects having no 
existence being procured, as sparks or flashes of light, floating specks 
(muscw volitantes), or dark waving lines, and connect with affections 
of the brain and optic nerve, as well as in dyspepsia; or the proper hue 
of objects may be changed; or one-half only of the object looked at may 
be visible (hemiopsia) ; or it may seem double (diplopia). 

The hearingi^ often painfully acute in cerebral inflammations, and in 
hysteria; it is obtuse in typhus fever; and may be impaired or entirely 
lost in certain afi'ections of the organ of hearing. It may be perverted 
in two ways ; unreal sounds may be heard, as ringing of bells, buzzing, 
falling of water, noise of wind, &c.; or sounds which are actually heard, 
are not appreciated or recognized. 

Smell may be exalted, diminished, and perverted. 

Taste is rarely augmented in disease, but very commonly impaired 
in acute disease, totally lost at the close of severe affections, and va- 
riously perverted in numerous instances. 

The power of voluntary motion, or motility^ may be increased, dimi- 
nished, abolished, or perverted (§§ 140, 141, 142). 

Increase of muscular strength takes place sometimes in the course of 
acute disorders accompanied by delirium, in cerebral inflammation, and 
in mania. Muscular debility attends most diseases, and may depend 
on a variety of causes, organic and functional. Complete abolition of 
voluntary motion constitutes paralysis. It may be indicative of lesion 
of the brain or of the spinal marrow, as apoplexy, spinal softening &c., 
or of injury to a nervous trunk ; or it may be only functional, as 
happens in some cases of hysteria. It may be partial or general : if 
it affect one side of the body it is called hemiplegia ; if the lower half 
of the body, paraplegia. Perversions of motility consist : 1, in trem- 
bling — a feeble involuntary agitation of the muscles involved — and 
occurs in the cold stage of fevers, in nervous affections, ataxic fevers, 
and in old persons ; it is caused, too, by the action of lead and mer- 
cury on the system, and by the prolonged use of strong coffee, alcoholic 
liquors, tobacco, and opium ; 2, rigidity^ in which there is diminution 
of muscular power, and gradual rigid contraction of the flexor muscles 
of the limbs. Rigidity of the upper extremities is a symptom of soften- 
ing of the brain. This symptom occurs too in cerebral extravasation, 
and in hysteria. 

The reflex or excito-motory system furnishes numerous symptoms of 
value. Its functions d^vQ exalted and perverted in spasm or convulsions, 
which may be tonic or permanent, or clonic or transitory. 

Cramp is a variety of tonic spasm, and consists in a sudden but per- 
manent contraction of one or more muscles, accompanied by hardness of 
the tissue and numbness, and inability to execute any movement of the 
affected part. The muscles of the calf of the leg and of the abdomen, 
are its chief seat. Pregnant women suffer especially from it, as well as 
those in whom an ovarian tumor may exist. It accompanies hysteria 
and painters' colic. When it occurs in old persons it is said to betoken 
cerebral softening. Many persons in health suffer from it. 



382 SEMEIOLOGY. 

Tetanus is another form of tonic spasm. Muscular contraction here, 
is equal and permanent, the aifected muscles being in a state of abso- 
lute immobility, 'which no internal or external effort can overcome. 
When the muscles of mastication only are affected, it is called trismus ; 
if the anterior muscles of the body, causing flexion, or curvature of the 
head and trunk forwards, emprostliotonos ; if the posterior muscles, 
bending the body backwards, opisthotonos ; or if the muscles of one 
side contract more powerfully than those of the other, so that the 
curvature is lateral, pleurosthotonos. 

In catalejjsif, the flexor and extensor muscles are in a state of perma- 
nent contraction, and the part implicated retains, during the whole 
attack, the position that it assumed at the moment of seizure, no mat- 
ter how uncomfortable that may be. 

Clonic spasm, in which contraction and relaxation rapidly alternate, 
is seen in convulsions occurring in children, hysterical females, and in 
some affections of the brain ; and in suhsultus tendinwn, an involun- 
tary and instantaneous twitching of the muscles, taking place in acute 
diseases of an ataxic form, more observable at the wrist than elsewhere. 
Hiccough is probably involuntary reflex contraction of the diaphragm. 
Defective reflex or excito-motory action is seen in paralysis of the 
sphincters, respiratory muscles, &c. (§ 154.) 

3Iorbid rhythmical movements of different parts of the body — as 
bowing movements of the trunk, rotatory movements of the head, vibra- 
tion of a single limb, and other anomalous motions — are sometimes 
noticed, and are considered by Dr. Paget to arise from disease of the 
cerebellum, or its commissures. ■• 

Reflected or sympatlietic sensations, where the impression made at 
one point is felt in another, as the pain at the extremity of the penis, 
due to calculus of the bladder, and other well-known instances, have 
been already mentioned (§ 156). 

The affective, perceptive, and intellectual faculties are variously 
affected in disease. More or less mental dejection, disquietude, and 
impatience are always manifested. 

The affective functions may be exalted in hypochondriasis, the patient 
being readily excited to strong hatred or profound friendship, or read- 
ily moved to tears on the expression of good-will towards him, and as 
easily aroused to suspicion and dislike. Moral sensibility is, on the 
other hand, sometimes totally abolished in mania and typhus fever, 
perfect indifference to self, and to those about the patient, being mani- 
fested. Perversion of the character and affections is sometimes met 
with in disease ; amiable persons becoming irritable and peevish ; the 
brave, timid; and the pusillanimous, resolute. 

Perversion of the perceptive faculties accompanies commonly insanity, 
and consists in illusion and liallucination. 

JExaltation of the intellectual functions is often a prominent symptom 
in melancholia, and sometimes occurs at the close of life, particularly 
in acute affections. Diminished or enfeebled action of these faculties 
is more common in disease than the opposite condition. It constantly 

' E(linbTir;;h Mcdic.-il and .Sur'rical Journal, Jan. 1847. 



DYSPNCEA. 383 

occurs in typhus fever. Perversion of the intellect constitutes deli- 
rium. Delirium is more common in the affections of infancy and 
youth, and in individuals of great nervous susceptibility. It is met 
with in diseases of the brain and its meninges, and in typhus fever, 
the exanthemata, and diseases of the chest and abdomen, as a sympa- 
thetic affection. It may be furious, mild, taciturn, or loquacious ; and 
may be constant or transient ; in the latter case, it may recur at regu- 
lar intervals. 

The symptoms furnished by sleep^ are complete suspension of sleep 
(insomnia) ; somnolency^ or drowsiness^ noticed in typhoid fever, and 
some cerebral affections ; coma^ of which there are two varieties : 1. 
Coma vigil, accompanied by delirium, muttering, and jactitation, the 
eyes being closed, except when the patient is spoken to : 2. Coma som- 
nolentum, in which the patient speaks only when aroused ; lethargy, a 
constant and more profound sleep, from which the patient may with 
difficulty be aroused, but seems unconscious, and speedily relapses ; and 
cams, or total insensibility. 

The voice rarely becomes stronger in disease, but may in delirium. 
In most maladies it is weaker, especially in those of the vocal and respi- 
ratory organs. It may be entirely lost, constituting aphonia ; or be- 
come hoarse, as in angina of the throat ; or shrill, or whistling^ or nasal. 

The speech is often affected in disease. It is trembling in some mala- 
dies, and slow or difficult in others, as typhus fever. Stammering, or 
defective articulation, occurs in fevers and cerebral affections. 

IX. The semeiology of the respiratory organs is so vast and import- 
ant, as to demand for its appropriate treatment a separate chapter. 
An outline only will be given here. 

Amongst the so-called vital symptoms (§ 606), dyspnoea, cough, and 
expectoration may be enumerated. 

Dyspnoea, or difficult or disordered breathing, is a symptom of great 
importance in affections of the lungs, and demanding every attention. 
It may be due to the causes, which, when excessive, produce asphyxia 
(§§ 134, 135, 136). The subjoined tabular view, by the author, of the 
causes of dyspnoea, showing the varied nature and origin of the symp- 
toms and diseases it is met with in, is taken from another work.^ 

PROXIMATE CAUSES OP DYSPNCEA, OR DIFFICULT BREATHING. 

1. By impeding the access of pure air to the lungs. 

a. Mechanical. 

Pdgidity of parts of the re- 'I f Ossification of cartilages ; induration of the 

spiratory machine j '^' \ pleura ; rickety distortions. 

Pressure on ditto . , e.g. Tumors on dropsies of the abdomen. 

( Effusions in, s-wellings of, tumors pressing on 

Obstructions of the air-tubes e.g. \ the air-tubes. 

, ( Spasm of the glottis; spasm of the bronchi. 

f Pleurisy, 

r, • i? J.1 1 r Effusions or tumors in ! Hydrothorax, 

Compression of Va^ lungs e.g. s i , ^ -o ^i ' 

^ o i/ 1^ pleural sac . . j Pneumothorax, 

[ Aneurism, <S:c. 



^ Williams and Clymer, Diseases of the Respiratory Organs, p. 91. 



384 SEMEIOLOGY. 

f Engorgement of the vessels. 

{(Edema, 
Hepatization, 
Tubercle, e^c. 
C Empliysema, 
Altered structiire . -i Dilated bronchi, 
1^ (Voniicie, is:c. 



the lungs . . . j 



b. Chemical. 

Deficiency of oxygen in the ") 
air . " . \^ . . / 
C. Vital. 



e.g. Mephitic gasses ; rarefied air. 



Pam of parts moved m re- 1 -m i ^ • • • • • c 

. J ^ e.g. Pleurodvne ; pleuritis ; peritonitis, ^^c. 

spu'ation . . . J ■^ . r i: 

T, , . ^ -I +.!•.* r Iniuries of the spinal marrow in the nech, &c. 

Paralvsis 01 muscles ot ditto e.a. ^ -r, •' . r. ^^ ^ . ■, ■ .... 

•^ (Paralysis of the bronchi []). 

Weakness of ditto . . e.g. Excessive prostration from ataxic fevers, &:c. 

Spasm of ditto . . . e.g. Tetanus : spasmodic asthma, .kc. 

2. By the state of the blood. 

a. Mechanical. 

Obstruction to the passage ") f Diseases of the heart and great vessels ; tu- 

of the blood . . • J \ mors pressing on them. 

b. Chemical. 

An excessively venous state e.g. Violent exertion : idiopathic dyspnoea (?). 
Deficiency of red particles e.g. Ana?mia ; chlorosis. 

3. By the xertous relations of respiratiox. 

Excessive sensibility of the 1 Hysteric dyspncea; cerebral fevers: neuralgia 

par vagum . . . / ^'^' (?). 

Defective, ditto . . . e.g. Coma ; narcotism. >S:c. (breathing slow.) 

Dyspnoea mav come on gradually or insidiously, or it may be violently 
sudden. The sensation is peculiar and distressing. When continuous, 
though but slight, it is singularly fatiguing and exhausting ; but when 
severe, even when paroxysmal, it causes intense suffering, attended with 
a feeling of impending death. There are several degrees of dyspnoea. 
"When the respiratory efforts of the patient do not oblige him to remain 
seated, it is simply laborious breathing. Ortliopnoea is the highest 
degree of difficult respiration, in which immediate suffocation seems 
threatened, and the erect posture is imperatively and instinctively as- 
sumed. 

Coufjh is generally symptomatic of disease of the air-passages, but it 
is believed by many that it may also depend on an affection of other 
organs, as tlie stomach, liver, &c., and thus be sympathetic. 

The tone or special character of cough varies, and may be hollow^ or 
harking., heard in the last stages of consumption, chronic bronchitis, 
and sometimes in nervous affections ; sliarp^ or ringing^ as in croup ; 
hoarse, in incipient catarrh, chronic laryngitis, and anginose affections; 
wheezing., as in asthma; or hcJcliing, in certain diseased conditions of 
the larynx. It is sometimes 'paroxysmal., as in hooping-cough and 
hysteria. Cough may be dry., attended with no excretion, or humid or 
mout^ with more or less secretion into the air-tubes. 

Tlie auscultation of the cough in health gives a quick, short, com- 
monly dull and indistinct, somewhat diffused sound, without hollow or 
tubular character, but attended witli a distinct sensation of succussion 
of the interior of the thorax (Walshe). The modifications caused by 
disease are: 1. iSronchial, which is harsh, rapidly evolved, very con- 



SPUTA. 385 

centrated, with marked succussion, and slight impulsion, and is met 
with in phthisis, pneumonia, pleurisy, and dilatation of the bronchi. 2. 
Cavernous, characterized by its metallic character and perfect hollow- 
ness ; strong impulsion, and transmission of sound towards the ear 
of the listener ; and accompanies tubercular excavation and dilated 
bronchi ; and 3. Amphoric, of a metallic or ringing character, symp- 
tomatic of broncho- pleural fistula, and large tubercular excavation in 
the lung. 

Spitting is the act by which the saliva, and other matters in the 
mouth are rejected. By expuition, or hawking, the mucus, &c., accu- 
mulated in the pharynx and posterior nares is got rid of, and is 
attended first by a peculiar inspiratory, snuffing effort, and subse- 
quently with a guttural cough. Expectoration, an effect of cough, 
signifies the expulsion of anything from the air-passages. The sputa 
are the matters which come from the bronchi, trachea, larynx, pharynx, 
and posterior nares, and are rejected *by these different modes. Their 
character furnishes very instructive signs, and may be studied with 
reference to quantity, consistence, form, composition, color, and odor 
in pulmonary disease. They are scanty in the first stage of acute 
affections of the lungs, and may be entirely wanting ; they are more 
copious in the decline of acute or subacute disease of the air-passages 
and lungs ; and are abundant in many chronic diseases of these organs. 
In bronchorrhoea, a pint or more of clear, slightly viscid, and frothy 
mucus may be expectorated. They vary in consistence and may be 
serous or watery, in the forming stage of bronchitis, pulmonary con- 
gestion, and vesicular emphysema; mucous, more or less viscid, and the 
result of acute inflammation of the mucous lining of the air-tubes, and 
of the pulmonary parenchyma, and hence met with in bronchitis and 
pneumonia; Sindi purulent, of the consistence of pus, due to the discharge 
of an abscess into the air-tubes, and seen in phthisis, and the third 
stage of pneumonia. The form of the S2:)uta depends very much on their 
consistence. When viscid they are elongated, stringy, and stellated ; 
they are sometimes frothy, flattened, and run together in the vessel, 
forming a homogeneous mass; and again they may be distinct, 
rounded, almost hemispherical, as the so-called nummular sputa, so 
often seen in the expectoration of tubercular phthisis, the bronchitis of 
measles, and occasionally in chronic bronchitis. The sputa sometimes 
are moulded into the shape of the tube or cavity from which they come. 
The large, rounded, flocculent, muco-purulent sputa of advanced phthi- 
sis, are often such as could only accumulate in a cavity (Williams). 
Tubular sputa are coughed up in plastic bronchitis and pneumonia. 
Kemak asserts, as the result of his observations, that the sputa of pneu- 
monia invariably contain ramifying bronchial coagula, which appear in 
the majority of cases between the third and seventh day of the disease, 
being rarely absent on the fourth and fifth. The basis of the sputa is 
usually the secretion of the mucous membrane of the air-tubes. Its 
composition varies with the altered products of secretion, and from the 
admixture of extraneous matter, as blood, tubercular matter, &c. There 
is great variety in the color of sputa. In the beginning of acute affec- 
tions of the lungs, they are whitish, or ashen ; in acute bronchitis, when 
25 



386 SEMEIOLOGY. 

secretion occurs, they are yellowisli or greenish; in pneumonia, the j are 
reddish or rusty^ yellowish or brownish, resembling prune-juice, from 
the admixture of blood. In bronchitis and the first stage of phthisis, 
the odor of the sputa is faint and sweetish. When secretion is copious 
in catarrh, the smell is sickening. When purulent matter is expecto- 
rated, the odor is fetid. In gangrene of the lungs, it is distinctive, and 
putrid. When an alliaceous odor is perceptible it is a sign of broncho- 
pleural fistula. An urinous smell of the sputa has been sometimes per- 
ceived, and two cases in which it existed have been described by Drs. 
Ha en and Stills, in which, on examination after death, a continuous 
passage from the bladder to the lung, was found. When a direct com- 
munication exists between the liver and the lung, as occasionally hap- 
pens, the sputa may be bilious. 

Pain is another vital symptom connected with disease of the organs of 
respiration. In acute bronchitis, there is usually a dull, heavy, aching 
pain, around the base of the chest, which is generally pretty constant. 
Soreness, too, is complained of in the sternal region and between the 
shoulders. Pleuritic pain is sharp, lancinating and sudden, and felt 
below the nipple. In phthisis, patients complain of darting pains from 
the anterior regions of the chest to the interscapular regions, and fre- 
quently about the clavicular regions, which are probably due to pleuri- 
tic complication. Constant pain between the shoulders is commonly 
regarded as a symptom of phthisis, but in Andral's opinion it is merely 
muscular, due to debility, and met with in many chronic diseases, 
particularly chlorosis. 

Physical exploration of the chest includes palpation or the applica- 
tion of the hand, mensuration^ percussion^ and auscultation. By the 
application of the hand, we not only obtain results confirmatory of 
those ascertained by inspection, with regard to alterations of form and 
of motion (p. 350), but also diagnostic indications derived from thoracic 
fremitus or vibration, and the presence oi fluctuation in the pleural 
cavities. By mensuration, we are enabled to detect with greater accu- 
racy than by inspection, the inequalities of size in the two sides of the 
chest, already spoken of. 

So much for the examination of the chest, by sight, touch, and mea- 
surement. We now come to its examination by hearing. There are 
certain sounds elicited from the chest by striking it [percussion), and 
others which are produced by the act of respiration, and the exercise 
of the voice, and which we become cognizant of, on applying the ear 
directly to the thorax {immediate auscultation), or with the interposi- 
tion of a cylinder of wood, called the stethoscope {mediate auscultation). 
In health, the chest, on being smartly struck, is generally resonant, 
although not to an equal degree in all portions. Those regions which 
are most thickly covered will sound duller than those more lightly coated. 
Whilst the axillary, upper-sternal, and infra-clavicular regions are 
very resonant from their light covering of muscle and fat; the 
acromial, infra-scapular, lower sternal, and left mammary are imper- 
fectly resonant, or dull. The modifications of sound, elicited by per- 
cussion in disease, are few. There may be increased clearness of sound 
caused by diminished density of the subjacent parts, and an increased 



BROxcni. 387 

proportion of air within the chest, as in pneumothorax and emphysema; 
or there maybe diminution of dearness or even positive clulness, owing 
to an opposite condition, as in pneumonia, pleurisy, phthisis, hydrotho- 
rax, &c. But, in certain diseases of the chest, sounds of a special 
character are elicited by percussion : 1, the ivooden^ resembling that 
yielded by mediated percussion of a table, and heard in chronic pleurisy 
with dense membranes ; 2, the tympanitic^ unnaturally clear and hollow, 
owing to the increased quantity of air beneath, and met with in pneu- 
mothorax and pulmonary emphysema ; 3, tubular^ resembling the sound 
emitted by the trachea when percussed — it occurs, when the larger 
bronchi are brought near to the surface, as in pleuritic effusion, and 
where tubercular cavities exist; 4, a7np'horic^ which may be imitated by 
filliping the cheek, when the mouth is closed and fully inflated, and is 
observed in large tuberculous cavities ; 5, the C7'acked-metal — hruit-de- 
'pot fele — resembling the amphoric, but peculiar and distinctive, similar 
to the sound produced by striking a broken pitcher, and happening in 
large tuberculous excavations near the surface. Percussion gives an- 
other valuable indication, too generally overlooked — the sensation of 
resistance in the part percussed — depending on increased density in the 
subjacent lung. Where the sense of touch is more delicate than that 
of hearing, this source of diagnosis is of great value. In acute phthisis, 
where, from the similar condition of both lungs, there is no means of 
comparison, it is often a precious sign. 

By pulmonary auscultation is meant, the listening to the sounds pro- 
duced in the lungs by the respiratory function. These consist in modi- 
fications of the natural respiratory murmurs, and adventitious sounds, 
which supersede them, called ronclii. Natural respiration may be 
variously altered. It may be exaggerated — increased intensity of the 
inspiratory and expiratory murmurs — and occur in the portions of lung 
adjoining those rendered unfit for the purposes of respiration, by ob- 
struction^ condensation^ or rarefaction. It is sometimes called supple- 
mentary respiration. Weah respiration is diminished intensity and 
duration of the respiratory murmurs, caused by the existence of an 
obstruction to the entrance of air in the part where it exists. The re- 
spiration may be totally suppressed, no air entering the region where it 
is met with, as where a plug of hardened mucus fills up a large bron- 
chus. It is sometimes incomplete, the inspiratory murmur being defi- 
cient at its beginning or close; this accompanies spasmodic asthma. 
Jerking respiration is where the inspiratory murmur is interrupted, and 
not evenly continuous, and is met with in incipient pleurisy, spasmodic 
asthma, and certain cases of tuberculous infiltration. Bronchial re- 
spiration resembles the natural respiration heard where the large 
bronchial tubes exist — the top of the sternum and root of the lung ; 
both murmurs are blowing, harsh, and dry, with increased intensity and 
prolonged expiration; it accompanies condensation of the pulmonary 
tissue, and occurs in pneumonia, tubercles, &c. The respiration is said 
to be cavernous when it resembles the sound produced by blowing into 
a hollow vessel ; and amphoric, when it gives the sensation of air pass- 
ing into a large empty cavity, and may be imitated by blowing into a 



388 SEMEIOLOGY. 

jug two-thirds full. They are met with in large tuberculous excava- 
tions. 

The various rlionchi are sounds which mask or suspend the natural 
murmurs of respiration, originating in the bronchi, and excavations of 
the pulmonary tissue, and caused by the passage of air along bronchi 
of altered caliber, or by air bubbling through fluid contained in these 
tubes, or in cavities in the lung. The rhonchi are either dry or 
humid. 

f r Sibilant, 

Dry \ Sonorous, 
I ( Dry crackling. 

KhoncM-l rn -i. i. 

' { Crepitant, 

Humid { Subcrepitant, 

] Mucous, 

[Cavernous. 

The sibilant and sonorous rhonchi are present in bronchitis, unac- 
companied by secretion, and are produced by the modified caliber of 
the air-tubes. Dry cracklijig rhonchus is composed of a succession of 
minute, dry, short, sharp, crackling sounds, few in number, rarely ex- 
ceeding three or four in a respiration, coexisting with inspiration. 
( Walshe.) It is heard in the first stage of phthisis, and is indicative 
of unsoftened tubercle in moderate quantity. 

Crepitant rhonchus resembles the sound produced by rubbing a lock 
of hair between the fingers, near the ear, or by the crepitation of salt 
on coals. It is the physical sign of pneumonia in the stage of engorge- 
ment, and in that of resolution. In subcrepitant rhonchus, the sound 
is more moist, and gives the idea of a greater amount of liquid. It is 
caused by the passage of air through minute bronchial tubes contain- 
ing liquid of variable consistence. It occurs in capillary bronchitis, 
idiopathic, and tubercular ; pneumonia, at the period of resolution ; 
pulmonary apoplexy; and oedema of the lung. Mucous rhonchus is 
produced by bubbles of large size, traversing liquid in bronchi of mode- 
rate or large size. Cavernous^ or gurgling rhonchus, is the bubbling 
of air through liquid, in a pulmonary cavern, and has a peculiar, hollow, 
metallic sound, and attends tuberculous excavations. 

"When the surfaces of the pleura become changed by disease, sounds 
are produced, giving the sensation of friction^ which may be detected 
by auscultation. 

On the application of the ear to the healthy chest, when an indi- 
vidual is speaking, a diffused buzzing is heard; except over the upper 
part of the sternum, over the large bronchial tubes, and on the middle 
line posteriorly, over the division of the trachea, and on either side of 
that division, between the spines of the scapula, and in the axilla, 
where the voice, imperfectly articulate, is transmitted with some degree 
of force and distinctness, constituting natural broncliopliony. In dis- 
ease, several modifications of vocal resonance occur. It may be dimi- 
nislicd in intensity, or be entirely suppressed, from the feeble conducting 
power of the substance of the lung, or intermediate substance, as in 
vesicular emphysema, and pneumothorax ; or, it may be exaggerated, 
constituting bronchophony — the unnatural density of the pulmonary 



IMPULSE OF THE HEART. 389 

tissue surrounding the bronchi rendering it a better conductor of 
sound. This happens in tuberculous accumuLation, and in pneumonia 
in the stages of hepatization. There is a peculiar modification of vocal 
resonance, to which Laennec gave the name of segophony^ from its 
tremulous, nasal, and metallic tone, resembling the bleating of a goat. 
It is audible over a limited surface, and its position may alter with the 
posture of the patient. The physical cause of this sign is generally a 
thin stratum of fluid usually contained in the pleura, and it, of course, 
is a sign of pleurisy, after effusion has taken place. Pectoriloquy 
signifies a state of vocal resonance in which the voice appears to resound 
in a hollow space, and is transmitted as articulate words to the ear of 
the observer. In its most perfect state, the patient appears to speak 
directly into the ear. ( Walslie.) The presence of an excavation, or 
dilated bronchus, whose condition permits free vibration, is necessary 
for its production, and it is present, therefore, in tubercular caverns 
and dilated bronchi. When the vocal resonance has a strong metallic 
tone, it is called amphoric, from its similarity to the phenomenon pro- 
duced by speaking into an empty pitcher. It is heard in the same 
affections as amphoric respiration. 

If the surface of the chest be auscultated during the cough of a 
healthy person, a short, dull, and indistinct, and diffused sound, quickly 
produced, is heard, attended with a sensation of succussion of the interior 
of the thorax. The morbid modifications of pulmonary cough are 
three : bronchial, cavernous, and amphoric. Bronchial cough is 
harsher and more concentrated than the cough in health. It is met 
with wherever there is unnatural density of the lung; when it is com- 
pressed by fluid ; or the bronchi are enlarged ; — as in phthisis, pneu- 
monia, pleurisy, and dilatation of the bronchi. Cavernous cough has 
a hollow and metallic character, and gives the sensation of being pro- 
duced in a small excavation ; there is strong impulsion in its trans- 
mission to the ear. It is associated commonly with cavernous rhon- 
chus. Amphoric cough is loudly resonant and metallic in its character. 
It occurs under the same circumstances as amphoric respiration. 

There is one phenomenon, detected by auscultation of the chest, 
which is common to the sounds of the respiration, of the voice, and of 
the cough — metallic tinkling. It is a quick, sharp, ringing sound, 
closely resembling that produced by gently striking a hollow metallic, 
or glass vessel, with a pin. ( Walshe.) It is heard in pneumo-hydro- 
thorax, with bronchial fistula, and it is said, sometimes, in certain 
excavations of the lungs. 

X. The signs derived from the circulatory system includes those of 
the heart and arteries. By auscultation of the heart, we study its 
imfnilse, its rhythm, and its sounds. By applying the fingers or ear 
over the space between the fifth and sixth ribs, a little to the inner 
side of a line running vertically over the nipple, a gentle and regular 
pulsation, synchronous with the pulse at the wrist, is perceived, and a 
slight shock felt. This is the impulse of the heart. It varies slightly 
with the position of the patient. The character of the impulse of the 
heart differs considerably in individuals, irrespective of disease. " It 



390 SEMEIOLOGT. 

is full and powerful in the strong and robust^ ; while in the weak and 
delicate, it sometimes amounts to scarcely more than an undulation, 
the precise situation of which it is sometimes difficult to determine. In 
the vigorous, but calm individual, it is strong, heaving, and diffused ; 
in the weak, nervous, and excitable it is smart, smacking, and very 
defined, or, as it were, concentrated ; when, indeed, the organ itself 
and the arteries leading from it are healthy, the impulse of the heart 
resembles in character and power, as well as in frequency, the pulse at 
the wrist. "^ A smart, or smacking impulse should not be confounded 
with a forcible, or heaving one. The first is indicative of an irritable, 
and, usually, a weak heart, whereas a deep, heaving impulse accom- 
panies a full or hypertrophied heart. In disease, as in health, a close 
correspondence will be observed between the impulse of the heart and 
the pulse at the wrist, unless some mechanical impediment exists to the 
course of the blood. In fevers and inflammations, when the pulse is 
strong, so is the heart's impulse ; when the pulse is feeble and de- 
pressed, the impulse is so likewise ; and when the pulse is small and 
vibratile, after hemorrhage, in anaemia, &c., the impulse manifests the 
same quality. In simple hypertrophy, the impulse is full, strong, and 
heaving, lifting the head of the listener from the chest, and somewhat 
diffused. In hypertrophy with dilatation, the impulse is more power- 
ful, and may be often felt over the whole prsecordial region. In simple 
ventricular dilatation, the impulse is feeble, scarcely amounting to 
more than a gentle tremor, but greatly diffused. In anasmic and 
nervous persons, or in atrophy of the muscular walls of the heart, with 
fatty degeneration (§ 544), the impulse is often exceedingly sharp, 
smart, and concentrated. When obstruction to the circulation exists 
anterior to the tricuspid valve, the impulse is visible at the scrobiculus 
cordis. When the mitral valve is diseased, and there is partial regur- 
gitation through the left auriculo-ventricular opening, along with the 
impulse at the scrobiculus cordis, there is frequently perceptible im- 
pulse between the cartilages of the third and fourth, or even second 
and third ribs of the left side. In pericarditis, the impulse varies in 
degree and situation with the amount of effusion. 

When the ear is placed on the proscordial region, a regular succes- 
sion of sounds is heard, with regular intervals — a long sound, a short 
sound, and an interval, making a complete circuit of the heart's func- 
tion. The regular performance of this constitutes the rhythm of the 
organ. ^ When the proper relation of the sounds to each other and to 
the interval is preserved, the rhythm is natural; when such relation is 
disturbed, and there is an alteration in the natural succession of sounds 
and intervals, the rhythm is unnatural^ and the action of the heart is 
said to be irregular. When this irregularity recurs at stated intervals, 
it constitutes inter mittence. Anything which unnaturally excites the 
action of the heart, as a moral impression or physical impediment, may 
disturb its rhythm. The most frequent cause of altered rhythm in 

' A Clinical Introduction to the Practice of Auscultation, &c. Ly 11. N. Iluglies, M. D., 
p. 202. 

2 Cai-penter's Principles of Human Physiology, 3d edit. p. 549. 



PULSE. 391 

disease, is valvular change. In great dilatation of the heart, and 
atrophy of the walls of the ventricles, the rhythm is altered; as well as 
in large effusions into the pericardium. 

The natural sounds of the heart, it has been already stated, are two ; 
the first, dull and prolonged ; the second, short and sharp, with hardly 
an appreciable interval between them, and may be fairly represented 
by the syllables luh-tuh — lub-tuh. Now the tone of these sounds may 
be unnaturally increased, or become louder as well as clearer, as in 
dilatation of the cavities, with thinning of the walls, without valvular 
disease ; when the sounds are only clearer, or shrill, there is only mus- 
cular atrophy of the parietes. A decrease in the cardiac sounds may 
be due to several causes ; as whatever interferes with the free action of 
the heart or its valves ; and preternatural thickening of the walls, or 
hypertrophy. The natural sounds of the heart may in disease become 
masked, or be replaced by unnatural sounds, called murmurs. These 
murmurs depend on conditions existing either in the cardiac cavities, 
or within the heart ; or in the pericardium, or outside of the organ. 



Endocardial / Blowing 
Murmurs 1 Murmur 



Bellows murmur 
Rasping " 
Filing " 

Sawing " 
Masical *' 



Exocardial J Rubbing murmur 
Murmur \ and its varieties. 

The endocardial murmurs are indicative 1st, of valvular lesions; 2d, 
of diseases of the constituents of the blood, as ansemia, &c. ; and, 3d, 
of nervous disease of the heart. The exocardial murmur, which is 
always a friction sound, results from the attrition of two roughened 
surfaces, and is symptomatic of pericarditis. For farther information 
regarding the semeiotic value of these murmurs, the reader may consult 
the numerous special works on the subject. 

The influence of disease upon the pulse is very great ; and the dif- 
ferent varieties of pulse are amongst the most valuable signs (§ 607). 
A great variety of pulses have been described, but all the important 
modifications of the pulse in disease may be included under two heads : 
1st, the force and intensity of the pulsations ; and 2d, the rhythm or 
relation of the pulsations to each other. A strong pulse is that which 
resists compression by the finger, and accompanies inflammatory affec- 
tions, particularly of the parenchyma of the solid viscera, as the lungs 
and liver; and the active hemorrhages. The condition of the vascular 
system at the time of attack, influences the production of this form of 
pulse. In plethoric individuals, and those of strong constitution, any- 
thing, which deranges the circulation, will cause a strong pulse ; and, 
therefore, it should not be always taken as an indication of the degree 
of inflammation. A weak pulse, where the artery is easily compres- 
sible, is met with under diff'erent circumstances ; as in all diseases 
attended with prostration, and in nervous and chronic affections, espe- 
cially when caused by perverted nutrition. It may be produced by 
fear. The diseases of children, old persons, and women, often exhibit 



392 SEMEIOLOGY. 

this pulse. A full pulse is where the rolume of the artery seems in- 
creased. It is the natural pulse of plethoric, thin, and tall persons, and 
occurs in all those diseases in which the pulse is strong, as well as in 
cerebral congestion and apoplexy, and in cardiac disease, particularly 
hypertrophy, with valvular complication. A small pulse gives the sen- 
sation of diminished diameter on being felt. It is caused often by 
narrowing of the aortic orifice, and, when present, should induce exa- 
mination of the heart. It is the pulse of the serous phlegmasiie, as 
peritonitis, pericarditis, inflammations of the stomach, intestines, blad- 
der, &c. ; it is met with in hysteria, hypochondriasis, and other nervous 
affections, as well as in chlorosis ;^ in the cold stage of fevers; and in 
diseases attended with violent paroxysms of pain. It is a symptom of 
adynamic and ataxic diseases, and of purulent resorption. Sometimes 
the artery feels like a thread beneath the finger — this is the Jih'form 
pulse. "When a vibratory sensation is communicated to the finger, the 
pulse is said to be hard, sharp, or contracted ; this is called, also, a 
corded pulse. It is encountered in the membranous phlegmasiog, san- 
guine congestions, active hemorrhages, neurosis, lead colic, ka. A soft, 
compressible, or liquid pulse, depends on a diminution of the tonicity 
of the arteries (§§ 123, 607), and yields with great readiness to pres- 
sure. In some adynamic affections, the pulse, though apparently dis- 
tended, on slight compression, gives way — this variety of the soft pulse 
has been termed gaseous, from the sensation experienced by the finger 
of the examiner. The pulse is ciuick, when the arterial stroke or 
diastole is very rapid, without any diminution in the intervals of pulsa- 
tion ; though generally associated with a frequent pulse, it is distinct 
from it. 

In the healthy adult the number of pulsations in a minute may be 
stated at 75 ; but it is liable to great variation from a number of 
causes, as position, &c.^ A frequent pulse is where the natural num- 
ber of pulsations is considerably exceeded. It constantly accompanies 
all febrile and inflammatory diseases, hemorrhages, &c. A slow or 
infrequent pulse, in which the number of pulsations falls below the 
healthy standard, occurs in apoplexy, acute tubercular meningitis, in 
some adynamic affections, occasionally in disease of the heart, &c. An 
equal pulse is that, in which the pulsations in a given time are alike in 
fulness, resistance, quickness, and velocity. The pulse is unequal, 
when tlie pulsations differ from each other in this respect. Inequality 
in rhythm is called the dichrotous pulse, which gives the sensation of a 
double beat, and has been compared to the rebounding of the hammer 
on the anvil. It is observed in convalescence from fever and other 
diseases (§ 123). AVhen a pulsation or beat fails, at regular and uncer- 
tain intervals, the pulse is called intermittent. 

When the stethoscope is placed over a large artery, a peculiar, dull 
sound is heard synchronous with the ventricular systole ; this may be 
masked or replaced by an unnatural murmur. Of all the unnatural 
murmurs heard in ascultation of the arteries, the blowing sound, and 
its various modifications, are the most common. It most frequently 

' Carpenter's rrinciplos of Human riiysiology, 3«1 cditiuii, p. 553. 



FECES. 393 

occurs in connection with diminution of the red corpuscles of the blood, 
as in anaemia, chlorosis, &c. ; but may be caused by ossification, dilata- 
tion of the walls of the arteries ; or from compression of the vessel by 
a tumor. 

XL The signs derived from the digestive organs next claim our 
attention. 

The state of the tongue in disease has always been considered of 
great importance, and has been already alluded to (§ 607). Although 
the importance of the signs which it furnishes have been exaggerated, 
they are interesting and valuable. The tongue in disease is to be stu- 
died in connection with its modifications in volume, form, movements, 
color, degree of moisture, nature of its coatings, its temperature, and 
sensibility. Diminution in the size of the tongue is a frequent symp- 
tom in typhus and other low fevers ; it is at the same time generally 
trembling and dry — conditions of equal gravity. A pointed, conical 
tongue was once supposed sufficient to establish the existence of gas- 
tritis. Experience has shown, however, that it indicates neither the 
nature nor the seat of the disease, or its danger, and that it depends 
entirely on the manner of contraction of the muscles of the organ. 
Impeded movement and distortion are valuable, as unfavorable signs 
in fevers as well as in cerebral disease. In paralysis, the deviation is 
usually more apparent than real; its seat being the buccal commissure 
and not the tongue. When the tongue presents on its upper surface a 
coating, it is generally evidence of some morbid condition. ■ Fasting 
will, in some persons, produce a white fur, and others who sleep with 
their mouth open are liable on waking, to have the tongue dry and 
dirty. Does the tongue faithfully represent the state of the stomach ? 
The results of careful and repeated observations on the part of Dr. 
Louis indicate, on the contrary, a great degree of independence of the 
conditions of the tongue and stomach. His observations, confirmed 
by others, show that the aspect of the tongue bears no relation what- 
ever to that of the stomach; the same state which coincides at one 
time with decided disease of the stomach, occurs at others where this 
organ is healthy. Albuminous exudation on the surface of the tongue 
is unconnected with any particular state of the stomach, but is a phe- 
nomenon of singularly bad augury, as it rarely appears until a few days 
before death. It occurred in one-eighth of the cases of phthisis ob- 
served by Dr. Louis. 

The appetite may be increased in disease to a degree constituting vo- 
racity, or bulimia, which is sometimes seen in pregnancy, hysteria, and 
insanity. Generally, however, it is diminished, and there is indiffer- 
ence (aiiorexia), or actual aversion to food. This is seen in most acute 
diseases. The appetite may be perverted, and articles which are 
noxious or disgusting may be eagerly sought after. 

Thirst is increased in acute affections, particularly of the stomach 
and bowels, after hemorrhage, and in diabetes. It is abolished in some 
cerebral diseases, and where there is coma. 

Vomiting occurs under various circumstances. It is a frequent ini- 
tial symptom of acute inflammatory and febrile affections. It is an 



394 SEMEIOLOGY. 

early symptom of pregnancy ; of lead, hepatic, and nephritic colic ; of 
cerebral disease ; and of hernia. 

Pain in the abdomen may proceed from various causes ; it may be 
due to inflammation of some of the contained viscera, and in that case 
it is aggravated by pressure ; or it may depend on over distension of 
some portion of the digestive tube ; on neuralgia ; hepatic, renal, intes- 
tinal, and lead colic, and is then generally relieved by pressure. 

Dysentery is often attended with a sharp burning pain, with a strong 
desire to go to stool ; this is called tenesmus. Acute colicky pains 
are termed tormina. 

^\iQ feces frequently undergo very important modifications. Their 
consistence when liquid may vary from that of water to that of pap. 
They are watery in serous diarrhoea, and Asiatic cholera ; in chronic 
inflammation of the colon they are mucous, and resemble white of egg. 
Sometimes they are harder than in health ; this is particularly the case 
in lead colic, and also, it is said, in cancer of the stomach. In these 
diseases, they often resemble the excrement of sheep, forming small, 
black, hard balls. The color of the feces varies. When there is defi- 
ciency of bile, they are of a grayish- white or clay- color ; when it is in 
excess, they are yellow or dark brown ; a dark-greenish hue is com- 
monly thought to depend upon the presence of bile, and this is particu- 
larly observed in children after the administratioif of calomel, but Dr. 
Golding Bird has shown it to be due to the presence of blood. Rhubarb 
stains the feces yellow. In dysentery they are reddish, or streaked with 
blood. When the blood is dark, and mixed with the feces, it usually comes 
from the superior portion of the intestinal canal. In meloena, the stools 
are of a pitchy blackness. When the blood is pure, and the evacua- 
tions are unattended with colicky pains, it is hemorrhoidal. The feces 
are semitransparent and colorless in Asiatic cholera, with whitish clots, 
and resemble rice water or turbid whey. The preparations of iron give 
them a black color. The alvine evacuations may contain shreds of 
false membrane, as in dysentery and diarrhoea, biliary or intestinal cal- 
culi, worms, &c. In diabetes and phthisis they often abound in fat. 
In some diseases they become intolerably fetid. In adynamic diseases 
they are very ofl"ensive, and in chronic dysentery exhale a peculiar ca- 
daverous odor. (For much interesting information on the intestinal 
excretions, consult Simon's Animal Ohemistry^ &c., translated by Dr. 
Day.) 

XII. The signs derived from' the urine are highly valuable, not only 
as regards the urinary apparatus, but other organs, and the system 
generally (§ 607). Many of these have already been noticed, and their 
semciotic value indicated (§§ 1G7, 176, 249, 2-54, 255, 257, 2G0, 809, 
384, 385, 448, &c.). We shall notice them here very briefly. 

Disease influences the (piantitij of urine passed. A healthy adult 
usually secretes during the day a pint and a half to three pints. In 
some aff'cctions of the kidneys there is complete suppression, no secre- 
tion taking place. The writer recently saw a case in which there was 
complete suppression during five days, without the supervention of 
coma. The patient recovered from that attack, but succumbed, without 



URINE. 395 

the occurrence of coraatose symptoms, to a second one ; and, on exami- 
nation, both kidneys were found extensively disorganized. In most 
inflammatory and febrile diseases, there is diminution in the quantity 
of urine, as well as in dropsy. Retention of urine — where it is secreted, 
but retained in the bladder — occurs as a consequence of paralysis, in 
typhoid fever, in hysteria, &c. Increase in the amount of urine takes 
place in diabetes, in the cold stage of fevers, and in hysteria. Fear, 
terror, and other passions of the mind, frequently render this secretion 
extremely copious. The tints of the urine in diff'erent maladies are of 
importance ; they vary from nearly colorless, to the usual pale amber 
color, up to deep brown. In chlorosis and hysteria, the urine presents 
a slight greenish hue ; if bile or blood be present, a variety of colors 
varying from red to brown, blackish-green, or apple-green, are pro- 
duced — the latter hue being occasionally indicative of the presence 
of cystine. Urine sometimes varies in consistence^ and instead of its 
usual fluidity, acquires some degree of viscidity ; in some cases only 
to be detected by the readiness with which it froths on agitation, and 
the length of time the bubbles remain, as in diabetes mellitus ; and in 
others sufficiently so to allow of being drawn into threads, from the 
presence of mucus, or pus in very concentrated and alkaline urine — the 
alkali reacting on the albuminous constituents of the pus, and convert- 
ing it into a mucous magma, as pointed out by Drs. Babington and 
Golding Bird. In some rare cases, urine fluid when warm, becomes 
semisolid like jelly, on cooling, from the presence of albumen or fibrine; 
this generally betokens some organic renal disease, though it is said to 
happen also in functional disturbance. Dr. Golding Bird states that 
in a few rare instances he has found urine, which was quite fluid whilst 
cold, gelatinizing when heated ; it was loaded with oxalate of lime. 
The odor of the urine in adynamic fever, after lesions of the spinal 
marrow, when long retained in the bladder, &c., is ofl'ensively aramo- 
niacal. The following are the general characteristics of the urine in 
inflammatory aff"ections : It is darker, being of a yellow, brown, or red- 
dish-brown tint ; has an acid reaction ; and augmented specific gravity. 
The urea may be absolutely increased, at or below the natural stand- 
ard ; the salts are always absolutely diminished. The composition of 
the urine becomes changed, if much blood is abstracted during the pro- 
gress of the inflammation ; it becomes clearer, specifically lighter, and 
the amount of urea decreases absolutely and relatively. At the height 
of the inflammation, the urine is clear and deeply colored ; when it 
subsides, there is a yellow or reddish sediment of uric acid and urates. 
The chemical composition of the urine has within a few years 
attracted a good deal of attention, as well as its microscopical exami- 
nation ; and by these means the several urinary deposits have been 
very attentively and advantageously studied. Deposits of uric acid 
and its combinations, present every shade of intensity of tint, from the 
palest fawn-color to the deepest amber or orange-red, and are often 
called red or yellow sand sedim.ents. They occur in fever, in acute 
inflammation, in rheumatism, in phthisis, in all the grades of dyspepsia, 
in all or most stages of diseases attended with arrest of perspiration ; 
in diseases of the genital apparatus; from blows and strains of the 



396 SEMEIOLOGY. 

loins ; from excessive indulgence in animal food ; or, the quantity of 
food remaining the same, from too little exercise. The earthy phos- 
phates (phosphate of lime, ammonio-phosphate of magnesia, and car- 
bonate of lime), are always white, unless when colored with blood ; 
soluble in dilute hydrochloric acid ; and insoluble in ammonia and 
liquor potasso3. On heating the urine, the deposit agglomerates into 
little masses. The occurrence of deposits of the earthy phosphates 
should be regarded as of serious importance, always indicating the 
existence of important functional, and, too frequently, of organic mis- 
chief. One general law appears to govern the pathological development 
of these deposits — that they always exist simultaneously with a de- 
pressed state of nervous energy, often general, rarely more local, in its 
seat (Bird). Deposits of oxalate of lime are regarded by Dr. Golding 
Bird as by no means so rare as is generally supposed, and he believes 
that it owes its origin to sugar, and is caused by derangement of the 
digestive organs. The urine may contain all or any of the elements of 
the blood. The serum may be alone effused, or be accompanied with the 
red globules. "Whenever the elements of blood appear in the urine, 
there is ample proof of the existence of active or passive hemorrhage 
of the kidneys or urinary tract. Albuminous urine occurs in Bright's 
disease, dropsy after scarlatina, &c. Pus is met with in the urine as 
the result of suppuration of the kidney, or of some portion of the 
genito-urinary mucous membrane, or of abscesses from adjoining vis- 
cera, opening into urinary cavities. The quantity of mucus in urine 
may vary under the influence of different degrees of irritation or inflam- 
mation, from a mere cloud to a viscid and tenacious fluid. The general 
indication of mucous deposits is an irritated or inflamed state of the 
genito-urinary mucous membrane. The presence of sugar in the urine 
is not uncommon in dyspepsia, and, when excessive, is an important 
sign of diabetes mellitus. The urine of pregnant women sometimes 
contains a whitish, opalescent, greasy pellicle, called kiesteine. 

The following simple and concise rules for the clinical examination 
of the urijie, condensed from Dr. Golding Bird's admirable work on 
Urinary Deposits (2d Am. Ed.), and from other sources, will serve as 
a guide for the immediate examination of the urine in the sick-room : — - 

I. Urine without any visible Deposit^ or decanted from the Sedi- 
ment. — If the urine be acid, a piece of litmus-paper immersed will be 
changed to red. Should no change occur, a piece of reddened litmus- 
paper should be dipped in, and, if the urine be alkaline, its blue color 
will be restored. When the urine is neutral, the tint of the test-paper 
is unchanged. 

A portion of the urine should be heated in a small test-tube, over a 
spirit-lamp ; and, if a white deposit takes place, it is evidence of the 
presence of albumen or of the earthy phosphates ; if the latter, a drop 
of nitric acid rcdissolvcs the deposit. 

If the urine be very high colored, and not rendered opaque by boil- 
ing, the coloring matters of bile or purpurine are present. Pour a thin 
layer on the surface of white porcelain, and add a few drops of nitric 
acid in the centre; if it be bile, there is an immediate and rapidly end- 
ing play of colors from bluish-green to red ; if purpurine, there is no 



URINE. 397 

change. When heat alters the color and transparency of high-colored 
ui'ine, blood is probably present. 

Excess of uric acid exists when, on adding nitric acid to deep-red 
urine, unaffected by heat, a brown deposit occurs. 

In a specimen of pale urine immerse the gravimeter, and if the sp. 
gr. be below 1.012, there is a great excess of water ; if above 1.025, 
there is either a large excess of urea, or sugar is present. If the 
former, by placing a few drops of the suspected urine in a watch-glass, 
and adding an equal quantity of nitric acid, and floating the glass on 
some cold water, crystals of the nitrate of urea will very soon be seen. 
To test for sugar, boil a small portion of the urine with an equal bulk 
of liquor potassse in a test-tube ; the existence of sugar is shown by the 
development of a brown color. 

If an excess of coloring matter, rich in carbon, be sought for, add a 
few drops of hydrochloric acid to hot urine in a test-tube ; if there be 
only an average proportion of pigment, a faint red or lilac color will 
be produced ; if it be in excess, it will be shown by a dark red or even 
a purple tint. 

In alkaline urine, if a drop of nitric acid be added, and a white deposit 
occurs, albumen is present. If brisk effervescence follows the addition 
of the acid, the urea has been converted into carbonate of ammonia. 

II. Examination of the Sediment Deposited, — If the deposit is floc- 
culent, easily diffused on agitation, and scanty and not dissolved by 
nitric acid, it is chiefly made up of healthy mucus, epithelial cells, and 
occasionally, in women, of vaginal and uterine secretions. 

If the deposit is ropy and apparently viscid, add a drop of nitric 
acid; if it is wholly or partially dissolved, it is composed of phosphates; 
if but slightly affected, of mucus. If the sediment falls like a creamy 
layer to the bottom of the vessel, the supernatant urine being coagula- 
ble by heat, it is pus. 

Urine sometimes appears opaque, from the presence of a light floc- 
culent matter diffused through it, neither presenting the tenacity of 
mucus nor the dense opacity of pus. Although scarcely sufiicient in 
quantity to interfere with the perfect fluidity of the urine, if a little be 
placed in a test-tube, and agitated with an equal bulk of liquor potassse, 
the mixture will often become a stiff transparent jelly. This peculiar 
appearance is demonstrative of the presence of the exudation, or large 
organic, globules formed under the influence of irritation, providing the 
urine does not coagulate by heat, for, should it do so, the existence of 
minute quantities of pus may be suspected. {Bird.) 

If the deposit is white, it may consist of urate of ammonia, phos- 
phates, or cystine. The first will disappear on heating the urine ; the 
second, on the addition of a drop of diluted nitric acid; whilst ammonia 
dissolves the third, the urine usually emitting an aromatic, and occa- 
sionally a fetid, odor. 

If the deposit be colored, it may consist of red particles of blood, 
uric acid, or urate of ammonia, stained with purpurine. If the first, 
the urine becomes opaque by heat ; if the second, the deposit is in visi- 
ble crystals ; and, if the third, the deposit is amorphous, and dissolves 
on heating the fluid. 



398 



SEMEIOLOGY. 



Oxalate, and more rarely oxalurate of lime, are often present dif- 
fused through the urine, without forming a visible deposit ; a drop of 
the suspected urine examined microscopically will detect the character- 
istic crystals. 

If the urine be of milky opalescence, with a cream-like layer on its 
surface during repose, an emulsion of fat with albumen is probably 
present. Agitate some of the specimen with half its bulk of ether, in 
a test-tube, and, after resting a few minutes, a yellow etherial solution 
of fat will float on the surface ; a tremulous a,lbuminous coagulum form- 
ing beneath it. 

The two following rules should be borne in mind, and will much 
facilitate the examination : — 

If the deposit he tvhite, and the urine acid, it, in the gi^eat majority 
of cases, consists of urate of ammonia; hut should it not disappear hy 
heat, it is phosphatic. 

If a deposit he of any color inclining to yelloiv, drah, pinh, or red, it 
is almost sure to he urate of ammonia, unless visible crystalline, in which 
case it cojisists of uric acid. 

The following tables of Dr. Bird briefly point out the readiest mode 
for the examination of crystalline deposits, both by chemical tests and 
by microscopic examination. The latter mode is the preferable one, 
from the information being more reliable and extensive, and from the 
economy of time : — ^ 

a. Tahle for discovering the Nature of Urinary Deposits hy Chemical 

Reagents. 

^ j Deposit -white . . . . . . .2 

( colored . . . . . . .5 

2 ( dissolyes by heat ..... Urate of ammonia. 

\ insoluble by heat . . . , . 3 

o r soluble in liquor ammouiiB . . . Cystine. 

( insoluble in . . .4 

. j soluble in acetic acid .... Earthy phosphates. 

\ insoluble . . . . ' . . Oxalate and oxalurate of lime. 

r f visibly crystalline ..... Uric acid. 

( • amorphous ...... 6 

r. r pale, readily soluble b}-- heat . . . Urates. 

\ deeply colored, slowly soluble by heat . do. stained by purpurine. 

b. Tahle for the Microscopic Examination of Urinary Deposits. 

^ j Deposit amorphous . . . . . .2 

( visibly crystalline . . . . .3 

,, f vanishes on tlie addition of liquor potassEC Urate of ammonia. 

( permanent after the addition of Phosphate of lime. 

r, j Crystals in well-defined octahcdra . . . Oxalate of lime. 

\ not octahedral . . . . .4 

. f in six-sided tiibles soluble in ammonia . Cystine. 

( not ta])ular, nor solul)le in ammonia . 5 

P j soluble in acetic acid . . . . (5 

'''* (^ insoluble in acetic acid . . . .8 

^ J imprisms or simple pennic . . . Neutral triple phosphate. 

'*' ( radiated or foliaceous . . . .7 

' [Tlie microscope required for the examination of urinary deposits is simple and unex- 
pcnsive. A complete, excellent, and economical instrument is manufactured and sold for 
about fifty francs (^10), by M. Nachet, of Rue de Serpente, Paris. — C] 



MODES OF DIAGNOSIS. 399 

_ r Crystals soluble in acetic acid with effervescence . Carbonate of lime. 

' • ^ witliout effei-vescence Bibasic-triple phosphate. 



— in dumb-bells or radiated . . . Oxalurate of lime. 

— spherical or colored . . . .9 
-- in lozenges or compound crystals . . Uric acid. 

— in spherical crystals .... Urate of soda or ammonia. 



(Much valuable information on the subject of the urine in disease 
may be had by consulting Simon's Chemistry of Man ^ and the excellent 
manuals of Dr. Golding Bird, Kees, Griffith, Markwick, &c., all of 
which are republished in this country.) 

XIII. The cutaneous exhalation, or j^ei'spii^ation, presents numerous 
points of semeiotic value. The average quantity of fluid transpiration 
is estimated at twenty-nine ounces daily, containing from seven to eight 
scruples of solid matter. Children perspire more profusely than adults, 
and men more than women. Profuse perspirations occur in acute 
rheumatism, and towards the decline of acute inflammations and fevers, 
and in the latter case are often critical. The night-sweats of phthisis 
are profuse and debilitating. The perspiration may be diminished or 
suspended, as during the early stage of acute disease, and in dropsy 
and diabetes. Perspiration may be general or local; it may be confined 
to the forehead, palms of the hands, epigastrium, soles of the feet, &c. 
Local sweats are sometimes critical. A case of this kind is mentioned, 
in which the sweat stood in drops on the feet, fresh drops springing up 
as fast as the feet were wiped; and it was curious that the surface 
affected occupied the posterior half only of each sole.^ The odor of the 
perspiration is naturally slightly acid. In rheumatism and in gout this 
becomes excessive. The odor is fetid sometimes in adynamic fevers ; 
mouldy in measles and scarlet fever ; and ammoniacal occasionally in 
typhoid fever. In insanity, a peculiar odor has been noticed ; and that 
of military sweat has been compared to the smell of chlorine, or rotten 
straw. A case in which sugar was detected in the sweat of a diabetic 
patient has been recorded by Nasse. 

XIV. The symptoms furnished by animal heat are rarious. The 
temperature of the human body may be increased ; this may be general 
or local. In idiopathic and symptomatic fever there is general heat of 
the surface (§ 437). 

In external local inflammation there is always at least the sensation 
of heat (§ 431); and the skin of the forehead is often hot in cephalalgia; 
the scalp in cerebral disease ; the integument of the chest in thoracic 
inflammations ; the hands and feet in phthisis, &c. Heat may be 
permanent or transient. There are diff"erent varieties of heat. The 
acrid heat of typhus fever, giving to the hand a peculiar burning 
sensation, increased by prolonged contact, is called color mordax. 
Diminution of temperature, or cold^ presents the same varieties in 
relation to its intensity, seat, type, and peculiar character. Coldness 
is a simple sensation of cold ; horri'pilation is accompanied with con- 
traction of the skin and the bristling of the hairs over the surface ; a 

* British and Foreign Medical Reyiew, vol, xx. p. 312. 



400 DIAGNOSIS. 

rigor is attended Tvitli involuntary tremor. A cMll of more or less 
intensity occurs as an initial symptom of febrile affections, and of the 
phlegmasise, particularly pneumonia. In cyanosis, the temperature of 
the body is generally low ; and this symptom is very common when the 
circulation, from whatever cause, is languid. Nervous and anj^mic 
persons suffer from coldness of the hands and feet. — C] 

611. The diagnosis of diseases is the distinction of diseases from one 
another. It may relate to diseases in their essential nature or pathology, 
or to those groups of symptoms that are classed as separate diseases by 
nosological arrangements (§ 597). In other words, the object of diag- 
nosis is to determine, either the intimate nature and seat of a disease, 
or its name and place in a classification of phenomena, grouped under 
the name of special diseases. According to the nosological arrange- 
ment, which has been recommended as the best at present (§ 600), the 
division into special diseases is as much as is practicable, founded on 
pathology, or the essential nature of disease; and diagnosis should also 
have a corresponding reference to this subject. Bat as it has been 
admitted that pathology is not sufficiently advanced to be the sole basis 
of nosology, so we must avail ourselves of other sources of information 
in regard to diagnosis. Accordingly, much of the materials of diagno- 
sis -are the results of simple observation or clinical experience ; and 
where these cannot be analyzed by any more rational mode, they may 
be measured or valued by the numerical method^ or counting and cal- 
culating the results in a large number of cases. Thus, diagnosis is 
chiefly derived from semeiology, and the results of clinical experience, 
arranged by pathology and statistics. In some instances, the causes 
and the treatment of disease give aid in the diagnosis. Thus the ma- 
larious character of a patient's residence, and the efficacy of quinia in 
curing him, will contribute important evidence as to the nature of his 
disease. 

612. Diagnosis may be general or special. G-eneral diagnosis compre- 
hends the distinction between the principles or elements of disease 
{§ 104); as, for example, between congestion and inflammation; between 
nervous irritation and structural disease, &c. Special diagnosis relates 
to the distinction of diseases according to their chief seat, where they 
have one (§ 599), or according to some other specific difference, where 
they have no particular head-quarters. Thus the special diagnosis of 
inflammations is between inflammation of the parenchyma of an organ 
and tliat of its investing membrane ; or between an intermittent and a 
continued fever. Special diagnosis also follows and distinguishes dis- 
eases in their farther differences of seat or character ; as the part or 
extent of a parenchyma or membrane inflamed, the type of a fever, kc. 
Thus special diagnosis is a branch of special pathology, and should be 
aided by an accurate and practical nosological arrangement. The mode 
of distinguishing between two diseases which resemble each other has 
been absurdly called differential diagnosis. It consists in pointing out 
the signs which are essential to the one and not to the other. The signs 
called pathognomonic, where they exist, are the chief guides in differ- 
ential diagnosis. 



MODES OF DIAGNOSIS. 401 

613. The modes of investigating and distinguishing diseases will 
vary much in different cases, according to the class of symptoms that 
first present themselves. This may be illustrated by the following 
problems : — 

General pathology having pointed out the general nature of a disease, 
it is required to determine its precise seat. Example. In a case in 
which fever, hard pulse, buffed blood, and local pain indicate inflamma- 
tion, the seat of the inflammation is determined by the chief seat of 
pain or uneasiness (in the chest or side), by the function most disturbed 
(difficult breathing and cough), to be in the organs of respiration ; by 
the secretion proceeding from the part (rusty, viscid expectoration), and 
from the physical signs (impaired breath-sound and stroke-sound in part 
of the chest, with crepitant rhonchus), to be in the parenchyma of the 
lungs ; that is, pneumonia. General pathology here commences the di- 
agnosis, which is completed by reference to symptoms explained by 
physiology and special pathology. 

Previous history, prominent symptoms, or physical signs, having 
pointed out the seat of a disease, it is required to determine its nature. 
Example. A person suffers from severe pain at the epigastrium ; the 
previous occurrence of symptoms of indigestion, and the situation of the 
pain, plainly show the disorder to be seated in the stomach ; the nature 
of the disease (whether nervous or inflammatory, &c.) is to be determined 
by general pathology ; guided by this, and finding an absence of symp- 
toms of inflammation, no increased heat of surface, no acceleration of 
the pulse farther than what the pain would cause, and no increase of 
the pain on the imbibition of warm or stimulating liquids ; and finding 
symptoms of predominate nervous properties, and the sudden attack, 
intense character, and transient duration of the pain which distinguish 
nervous and spasmodic affections, we decide that the disease is gas- 
tralgia or gastrodynia, and not gastritis. The diagnosis which is begun 
by local symptoms is completed by reference to the principles of pa- 
thology. 

Lastly, which is a common case, symptoms being too few or too 
inconclusive to lead the diagnosis, both the seat and the nature of the 
disease are to be determined. A person complains of general uneasi- 
ness, weakness, and chilliness, with various functional symptoms, but 
none of a prominent character. Clinical experience has taught the 
practitioner that such are the symptoms of incipient fever ; and he pro- 
ceeds to investigate farther the nature and cause of the fever. If he 
finds, on close examination of the functions and physical condition of 
the different organs, that one is the seat of marked inflammation, and 
that the fever is not typhoid, he judges that the fever is symptomatic 
of the inflammation ; but if signs of marked local inflammation be absent, 
yet the fever continues with increasing symptoms of depression, weak 
frequent pulse, brown dry tongue, sordes on the teeth, low delirium, &c., 
he recognizes typhoid fever, resulting from the influence of a morbid 
poison on the system (§ 105). 

614. Thus every department of medical knowledge is brought to bear 
on diagnosis ; and in nd branch is the information as well as the judg- 

26 



402 DIAGNOSIS. 

ment of the practitioner more brought to a test. Natural shrewdness 
and tact, with some general knowledge of the nature and treatment of 
disease, may sometimes enable a comparatively ignorant person to prac- 
tice medicine with an appearance of success ; but such a person can 
make no hand of diagnosis ; and he wisely either evades the whole sub- 
ject or expresses his opinions in vague terms, and scrupulously avoids 
their being brought to the test of the scalpel. The well-informed prac- 
titioner, on the other hand, feels that this is the subject which requires 
the full application of his mental powers and knowledge, as well as the 
keen exercise of his powers of observation ; and in proportion as his 
senses are practised in observing, his information well arranged in re- 
lation to what he observes, and his judgment matured in discriminating 
and deciding the results, so will he be successful in diagnosis, and in 
applying it to prognosis and practice. 

615. In investigating the symptoms of a case with a view to diag- 
nosis, prognosis, and treatment, the observation is first drawn to those 
which at once declare themselves in the aspect of the patient, the ex- 
pression of the countenance, the complexion, the posture, the manner 
of the movements, speech, &c.; and these give important information 
to the observing practitioner at first sight, and whilst he is interrogat- 
ing the patient. After the first few statements of complaints, which 
are generally volunteered by the patient, the questions should be 
directed to the liistory of the ailment, including the previous state of 
JiealtJi and Jiahits, with regard to food, clothing, occupation, residence, 
&c., any former illness, the mode of the present attack, and its supposed 
cause, t\\Q former symptoms, and treatment, if any has been employed. 
The answers to these questions will direct the inquiries in the most 
searching manner with regard to the present state and symptoms. The 
mode of investigating these will partly depend on the clue given by 
the answers to previous questions; but the practitioner must not permit 
himself to be so far led by the patient's statements as to omit to exa- 
mine the state of all the important organs and their functions. The 
nervous system and its functions (sensorial, sentient, excito-motory, and 
sympathetic); the organs of circulation and their functions (pulse of 
heart and arteries, capillary circulation of surface and visible parts, 
temperature, state of veins, &c.) ; the organs of respiration and their 
functions (breathing, cough, expectoration, voice, arterialization of the 
blood) ; the organs of digestion and their functions (tongue, appetite, 
digestion, &c.) ; the organs of secretion and excretion and their functions 
(liver and intestines, kidneys, bladder, and the skin) ; the functions of 
nutrition and assimilation (to be judged of by the condition of the 
flesh and comparative weight of the subject); the organs of locomotion 
and tlidr functions ; the organs of generation and their functions ; are 
severally to be made the subjects of inquiry and physical examination 
to such an extent as may be requisite to inform the practitioner of 
their true condition and connection with the past or present disease. 

The object of a complete investigation of the state of the patient is 
not merely to determine the particular disease under which the patient 
labors, but to discover what is healthy as well ?is what is morbid in his 



INVESTIGATION OF SYMPTOMS. 403 

condition. The prognosis or estimation of the amount and event of 
the disease, and the application of treatment, requires this full inves- 
tigation. We have to consider, not merely disease in the hody^ but the 
body in disease; and it is by losing sight of this great practical axiom, 
that minute or microscopic inquirers, who may be singularly successful 
in special diagnosis, signally fail in prognosis and in practice. 



CHAPTER YI. 

PROGNOSIS— FOREKNOWLEDGE OF THE RESULTS OF DISEASE. 

616. Prognosis is that knowledge by which we are enabled to foresee 
the course, duration, and event of a disease. Like the treatment of 
disease, it may be either empirical or rational. 

Umjnrical prognosis is that which is founded on experience or observ- 
ation only, without regard to the nature of the disease or the reasons 
which determine the results. It consists in the observation of the c/ood 
and bad symptoms — that is, those symptoms which have, in a great 
majority of cases, been followed respectively by a good or a bad result. 
This mode of prognosticating the events of disease was the only one 
attainable in the early ages of medicine. The "prognostics" of Hip- 
pocrates chiefly consisted in the enumeration of good and bad signs ; 
and the frequent truth of the distinctions which he has made on these 
points, show the extent and accuracy of his observation, or of the 
sources from which his information was drawn. In a limited sense, 
the same faculty of empirical prognosis is often acquired by nurses or 
other non medical attendants of the sick. These can often tell when 
a patient is getting better or worse, by the appearance of the counte- 
nance, the state of the voice, the mind, the strength, the breathing, 
the excretions, <&:c., whilst they may be in total ignorance of the nature 
of the disease and why the signs are good or bad. This kind of prog- 
nostic knowledge, although it may be useful in enabling a person to 
pronounce a patient better or worse, falls far short of that which ought 
to be expected of the scientific practitioner, who should not only have 
a greater number of prognostic symptoms within his reach, but should 
be able to foresee them, so as to anticipate, and, if possible, to influ- 
ence them in a favorable manner. 

617. Rational i^'^'ognosis is the estimation of the importance and 
tendencies of a disease from a knowledge of its causes, its true nature 
and symptoms, and of the power of treatment in regard to it. Like 
rational diagnosis (§ 614), it derives its evidence from all available 
sources, and makes the best use of this evidence by analyzing it, and 
thus determining its value. Thus, in the early stage of inflammation 
of the lung, the discovery of the nature and scat of the aff'cction at 
once shows the presence of a serious disease, whatever may be the 
state of the present symptoms. The practitioner, in forming a rational 
prognosis, takes into account the extent of the inflammation, knowing, 
iVora experience as well as from reason, that this is a source of danger; 
he considers the duration of the attack, and from the signs and symp- 



SOURCES — THE SUBJECT. 405 

toms judges ■whether it is increasing or not. These considerations 
may give him some insight into the severity of the disease, but his 
prognosis is to be determined by farther conditions. He knows, by 
experience and reason, that inflammation of the lungs, although always 
a dangerous disease, becomes much less so w^hen it is at a stage and in 
a subject in which antiphlogistic remedies can be well borne ; thus, at 
an early stage, in a young and vigorous subject, even the most extensive 
inflammations may be cured by bloodletting and other means judi- 
ciously employed; but if the disease has advanced far, and the function 
of respiration has been for some days impaired by it; if the subject be 
feeble, from infancy, or from extreme age, or from previous disease, 
from intemperate habits, from a complicating disorder, or from any 
other cause, the prognosis becomes more unfavorable, inasmuch as 
there is little power in the system to bear the appropriate remedies, or 
to withstand the evil effects of the disease. 

To take an example of another disease. In continued fever, certain 
symptoms have been found by experience to be of an unfavorable cha- 
racter. The pathological practitioner profits by this experience, but he 
analyzes the results and goes farther. He knows that the appearance of 
petechige, congested face, and stupor, at the commencement of fever, are 
bad symptoms, but that they are so, mainly in proportion as they arise 
from the changed state of the blood induced by the depressing cause of 
the fever ; and when, as it sometimes happens, these symptoms appear 
without any corresponding depression of the heart's power, as manifest 
by extreme frequency and weakness of the pulse, they are by no means 
of such unfavorable import, but may arise from the plethora of the sub- 
ject. Again ; symptoms referable to the excito-motory system (§ 153) 
— such as subsultus, hiccough, and convulsive affections — are gene- 
rally unfavorable in continued fever; but they are so only when arising 
from the severe operation of the cause of the fever on the nervous cen- 
tres ; they are much less so when occurring in a nervous subject, in 
whom slight causes may induce them. The same remark may be made 
of a state of stupor, which would be of most serious import if depend- 
ent on fever alone ; but it maybe induced by slight fever, or other cause, 
in an hysterical subject. The pathologist is prepared for these differ- 
ences, and can qualify his prognosis accordingly. He can trace the 
danger of bad symptoms, beyond the symptoms themselves, to those 
interferences with vital functions which render these symptoms dan- 
gerous, and of which these symptoms are not always the true expo- 
nents. 

618. As our limits do not admit of details, it must sufiice to enume- 
rate the chief circumstances from which a rational prognosis may be 
formed with illustrative examples. These may be arranged under the 
two general heads : 1. Those relating to the patient or subject ; and 2. 
Those referring to the disease. 

619. The age of the subject. — Acute diseases are ill borne at either 
extreme of age, when the powers of reaction are less energetic to sustain 
the struggle. Hence infants and aged persons are often carried off by 
acute attacks. Acute diseases prevail more in youth and middle age 
than in advanced life, in which affections tend to assume a chronic form ; 



406 PROGNOSIS. 

also from want of that power of reaction and resistance bj which, in 
more vigorous age, morbid actions are thrown off. [In early infancy 
there is always hope, even with the most dangerous symptoms. " L'en- 
fance est T age des resurrections,'" says Chomel. It is at this period 
of life, that the well-known adage uhi vita, ihi spes, is so applicable. 
In old age, on the contrary, acute diseases which assume a severe form 
almost always terminate fatally. In middle age, the chances are more 
favorable, and are greatest in youth and adolescence. The exceptions 
to this rule are the eruptive fevers, which are less dangerous in infancy, 
and certain organic affections, which are said to advance less rapidly 
in old age. — C] 

The sex of the loatient. — Nervous diseases are most common and ob- 
stinate in the female sex ; but they are more serious in the male sex. 
The occurrence of the catamenia is often favorable as their suppression 
is unfavorable in the course of the disease. Pregnancy and lactation, 
during their continuance, suspend or retard the progress of tuberculous 
disease, and other disorders of the nutrient function, and the cessation 
of these conditions may excite the disorders into fresh activity. Erup- 
tive fevers, especially smallpox and scarlatina, are peculiarly fatal to 
women during and shortly after pregnancy. 

The temperament of the patient. — In the sanguine temperament, dis- 
orders are apt to be acute, or tending to a speedy termination, favorable 
or unfavorable ; in the phlegmatic temperament, more chronic, and not 
uncommonly latent or obscure in their symptoms; whilst in the nervous 
temperament, the symptoms are very prominent, often exciting much 
suffering and alarm where little or no danger may exist ; and they are 
likewise remarkable for their mutability. 

Previous diseases of the patient, — The same disease having occurred 
before prevents or renders milder a subsequent attack, in the case of 
eruptive fevers, hooping-cough, &c. ; but increases the tendency and the 
danger in case of apoplexy and most structural diseases. Albuminuria 
with dropsy is more curable, when ensuing after scarlatina, than when 
after other causes ; but rheumatism after scarlatina and gonorrhoea is 
often unusually severe and intractable. After continued fevers, and 
other debilitating diseases, inflammations often assume a subacute or 
chronic form, which may escape attention, and produce serious organic 
disease. 

Present diseases ofthepatient. — These generally increase the severity 
or intractability of the new disorder, especially if they be structural. 
Thus infectious disorders and fevers are peculiarly fatal in persons with 
diseased heart, lungs, kidneys, or brain. Yet moderate hypertrophy of 
the heart is rather a favOrable circumstance in phthisis. Cutaneous and 
some other external diseases, sometimes suspend attacks of gout, gravel, 
diarrhoea, &c. Extensive emphysema of the lung supersedes tubercles 
and most other lesions of the parenchyma, whilst it renders the bronchial 
surface and liver the scat of almost constant congestion or inflammation. 
Cancer supersedes tuberculous disease, and reduces the proneness of the 
subject to inflammation. 

Previous habits of the patient. — Habitual intemperance, and excesses 
of all kinds, enhance the danger of all serious attacks and accidents. 



ETC. OF THE DISEASE. 407 

Extreme privations, or over-fatiguing employments, make people liable 
to fevers, and other depressing diseases, and reduce the powers of reac- 
tion against them ; and the same remark will apply to close confinement 
and want of sleep. 

Condition of the 2^(ttient at the time of the attach. — Extreme weak- 
ness or exha'ustion from any cause renders persons had subjects for 
most diseases. Plethora increases the intensity of inflammatory affec- 
tions. Simultaneous excitement of any organ, as of the brain from 
moral causes, may add a dangerous complication to continued fever. 

620. The cause of the disease. — Epidemic, endemic, and infectious 
disorders, are chiefly serious in proportion to the intensity of their 
cause. Thus the endemic of a hot climate is more dangerous than that 
of a cold climate ; an infectious disorder propagated in close habitations 
is more severe, from the concentration of its cause and co-operating 
influences, than one arising from more diluted and simple infection. 
By knowing the source of the disease, some estimate may be formed of 
its future severity. 

The situation and nature of the disease. — The more important to 
life is the part attacked, and the more the disease interferes with its 
function, the more dangerous will it be. Thus the heart, the lungs, the 
medulla of the nervous system, the kidneys, and the blood, cannot be ex- 
tensively attacked without great danger to life ; and if the disease goes 
on to affect structure, as in inflammation, the danger is prolonged in 
proportion. In a few cases disease attacking an unimportant part, as 
the skin, or an extremity, may prove dangerous on account of its tend- 
ency to spread to other parts or infect the whole frame, as in the 
instance of cancer, gangrene, inoculated poisons, hydrophobia, &c. 

The extent and j^rogress of the disease. — The greater the extent of 
the disease, the more serious it will be in case of inflammation ; but 
the severity of the symptoms is often not in proportion to its extent ; 
intense and circumscribed inflammation causing more prominent symp- 
toms than that which is extensive and diffusecl. The rate of the pro- 
gress of disease most materially influences its effect on life and health. 
Thus the structure of the lungs, heart, kidneys, or liver, may become 
diseased to a most extraordinary amount, without destroying life, if the 
advance of the lesion is very gradual ; whilst a third or fourth of the 
same mischief would prove fatal, if it were induced suddenly. 

621. The character of the symptoms. — This is exhibited in the de- 
tails of each disease. Those symptoms augur favorably which show a 
power of moderate and regular reaction, and a return of the functions 
to their natural state. The removal or alleviation of the more dis- 
tressing symptoms of disease^the restoration of the natural appetites, 
and feelings, bodily and mental — the regaining of strength — the return- 
ing regularity and moderation of the pulse and other signs of equal cir- 
culation — the disposition to sleep tranquilly, and wake at the usual 
times — secretions that have been interrupted or diminished being re- 
stored, and often in increased quantity, as if from accumulation, as in 
the case of critical perspirations, deposits in the urine, &c. (§ 448) — 
are among the chief signs of approaching recovery. 

622. Bad or unfavorable symptoms are those which arise from such 



408 



PROGNOSIS. 



an impediment of one or more of the functions more immediately con- 
cerned in the sustenance of life, the circulation of the blood, respira- 
tion, nutrition, and excretion. In proportion as these functions are 
speedily and considerably impaired, life is threatened, and there is an 
approach to its destruction, by one or other of those terminations, 
"VN'hich are called modes of death. Thus, there is death by syncope — 
cessation of the circulation ; by asphyxia^ or apnoea — interruption of 
the respiration ; and by inanition. To these may be added, death by 
the pernicious influence of excrementitious matters, and by poisons, 
"which cause death in various modes. These different modes of death 
are most distinct when induced so speedily as to leave the functions, 
which they do not directly aifect, comparatively vigorous and outliv- 
ing that which has been chiefly injured. Thus, in sudden death from 
causes stopping the respiration, the heart continues to act for some 
time, until the death which has begun with the breathing function 
reaches it also. 

623. If we farther trace the operation of these different modes of 
death, we shall find that they all agree in affecting the blood, either by 
altering its composition or by arresting its circulation ; and it is through 
one of these means that death extends to all the functions. Thus, in 
death by cessation of the heart's action, the circulation is at once ar- 
rested ; hence this is the most speedy mode of death. Inanition ob- 
viously operates by reducing the circulating material, and by farther 
weakening the organs by which the circulation is carried on. Asphyxia 
we have already found (§ 235) both to impede the circulation and to 
alter the condition of the blood. Excrementitious matter retained in the 
blood, and extraneous poisons, also operate in various ways : by impair- 
ing the irritability of the heart ; or by injuring the medullary nervous 
function (§ 154), on which respiration depends; or by arresting the 
passage of the blood through the capillaries (§ 298); or (and this pro- 
bably includes some of the former modes), by so changing the proper- 
ties of the blood itself, as to render it unfit for its office of sustaining 
the activity of the functions ; and the operation of all poisons, as well as 
of other causes of death, may thus be traced to defective circulation or 
composition of the blood. It is the more necessary to keep these points 
in recollection, because they show why death from disease often takes 
place without distinctly beginning with any set of functions; but all 
fail from want of proper blood, their natural support. 

624. It will be useful to mention the chief varieties of the modes of 
death above noticed, and to state their symptoms, which may become 
available as prognostic signs of the approach of death. 

])(3atli (ccssjitinn of function') ])cp;inninQ; at the heart \^r^ , , ^.i • ' 
^ ; C5 b 1^ Gradual=astncnia. 

— — )»cp.inninj^ at the breathing apparatus=Asphyxia, or apnoea. 

— — bo;riiininf^ at the l)rain=Corna. 

— — ]n'.\rh\\\\n\r at the me(lulla=Paralysis. 

— — beginning in tlie blood^Necrtcmia (vexfoj, dead; aifxa., blood). 

025. Death by cardiac syncope, or sudden cessation of the heart's 
action, may occur in two ways : 1. By this muscle losing its irritability 
(§ 116), so that it ceases to contract ; and 2. By its being affected with 



MODES OF DEATH — BY SYNCOPE. 409 

tonic spasm (§ 114), in which it remains rigidly contracted, losing its 
usual alternation of relaxation. In both these cases, death is quite in- 
stantaneous ; the subject suddenly turning pale, falling back or drop- 
ping down, and expiring with one gasp. In the first case, both sides of 
the heart are found, after death, distended with blood ; and if the ex- 
amination were made soon after death, the blood in the left cavities 
would be found to be florid. In the second case, the heart appears 
small and very hard ; the ventricles (or at least the left) are found so 
firmly contracted, that the cavity is almost obliterated, and contains 
no blood; the muscle is very firm; but after maceration in water, or 
even without it, in two or three days, the walls of the ventricles yield 
to the pressure of the fingers, and the cavities may be restored to their 
normal dimensions. This state of the heart was long mistaken for con- 
centric hypertrophy, until Cruveilhier and Dr. G. Budd pointed out its 
true nature. 

Although syncope by loss of irritability (paralysis) and syncope by 
spasm, appear to be opposite states, yet they arise from somewhat 
similar causes. In animals, wounds of the heart are followed some- 
times by the one, sometimes by the other. Death by sJiocJc, as from 
tearing off a limb, a violent blow on the epigastrium, crushing the 
brain or spinal marrow, is sometimes caused by spasm, although more 
frequently by paralysis of the heart. In sudden death from drinking 
a quantity of raw spirits or of very cold water when the body is heated, 
the heart has been found contracted. 

Syncope by loss of irritability of the heart is the more common 
case ; and, besides, in the examples above given, it may be induced by 
the operation of large doses of certain poisons called sedative — such 
as the upas antiar, infusion of tobacco, aconite, and digitalis ; and in 
combination with other effects, by large doses of hydrocyanic acid, 
strychnia, oxalic acid, arsenic, preparations of baryta, and various ani- 
mal poisons. Mr. Blake found the power of the heart destroyed by 
solutions of various saline matters injected into the veins, especially 
salts of potass, magnesia, zinc, copper, lime, baryta, and lead ; but 
these results do not correspond with what we find of the operation of 
these substances when introduced into the stomach. 

The diseases in which death by cardiac syncope sometimes takes 
place, are — those of the heart (but more rarely than is commonly sup- 
posed); hemorrhagic apoplexy, attended with much injury to the sub- 
stance of the brain (§ 364) ; anaemia (§ 270) ; and adynamic fevers 
(§ 105). As it occurs suddenly, there can scarcely be said to be symp- 
toms; but sometimes an approach to it has been manifested in previous 
attacks of common syncope or faintness, in which the action of the 
heart becomes weak, irregular, and intermittent; and the partial fail- 
ure of the circulation is evinced in the paleness of the face, lips, and 
general surface, often with cold perspiration; the failure of the senso- 
rial functions [defectio animi)^ loss of consciousness and volition more 
or less complete, sometimes attended with various convulsive movements 
(§§ 153, 265); the eyes turning up or becoming fixed or glazed, and 
the pupils dilated. The different effects of posture on the forms of 



410 PROGNOSIS. 

syncope have been before noticed (§ 70); and they may be presented 
in cases in which cardiac syncope ultimately proves fatal. The 
recovery from this faintness is often attended with shivering, vomiting, 
sighing, gasping, yawning, and various distressing sensations of noises 
in the head, flashes in the eyes, palpitation, depression of spirits, &;c. ; 
whilst the pulse regains its strength and regularity, and the color and 
warmth return to the surface. After this may ensue a reaction, like 
that which occurs after great losses of blood (§§ 266, 362). 

626. Death by the gradual cessation of the heart's action has been 
termed astlienia (a, not^ o9evoj, strength). This is the mode of termina- 
tion of many diseases, especially those which destroy life by exhaust- 
ing the strength, without any direct interference with the more vital 
functions. Thus long-continued fevers, delirium tremens, gastritis, 
enteritis, peritonitis, sometimes tetanus, hydrophobia, and inflammation 
of the brain — hemorrhages, and various discharges of animal fluids — 
such as diarrhoea, diabetes, extensive ulcers, or abscesses, &c., proving 
gradually fatal — inanition from want of sufficient food, and several 
others — reduce the power of the heart, and with it the functions of the 
whole body, to a lower and lower state, until at length the heart flut- 
ters, and dies. 

The symptoms of the approach of death by asthenia are — increasing 
weakness of body and mind, whilst there may be no marked derange- 
ment of any particular function of either; increased frequency and 
diminishing strength of the pulse ; the face, lips, and other parts of 
the surface gradually become paler and paler, or of a death-like sai- 
lowness ; the extremities lose their warmth, and often become oedema- 
tous; the appetite fails; the tongue becomes sometimes dry and brown, 
sometimes furred, and the mouth aphthous (§483); the excretions first 
are imperfectly voided; then the sphincters lose their power (the weak- 
ness reaching their excito-motory function), and involuntary discharges 
of urine and feces may take place; and this state of sinking in a few 
hours terminates in death. The symptoms above described are those 
of progressive loss of power, not confined to the heart, but through its 
failure and that of the circulation of the blood, of which it is the chief 
instrument, becoming extended throughout the whole frame. But with 
this general debility there are often symptoms of partial excitement 
and reaction, which sometimes mark the sinking state. Thus a febrile 
excitement of a hectic kind (§ 471) may come on, giving slight tempo- 
rary strength to the pulse, flush to the cheek, life to the eye, and a sort 
of flickering reanimation to the whole frame. Sometimes the excite- 
ment is more partial, aff'ecting the brain, as with delirium; or the me- 
dulla, as with suhsultus tendinuni, hiccough, or other slight convulsion; 
or the stomach, as with vomiting, &c. Or, in the sinking state, some 
functions may become obscured before others, in consequence of con- 
gestions, efi'usions, or even low inflammations occurring in the capillaries 
of some organs (§ 290), as the powers of the general circulation fail. 
Thus the death by asthenia may become somewhat complicated with 
coma from congestion or eff'usion within the head ; or with dyspnoea 
from congestion in the lungs; or somewhat similar symptoms may arise 



MODES OF DEATH — BY APXCEA. 411 

from the early failure of the excreting organs, and the retention of 
excrementitious matter in the hlood (§ 249). 

627. Asphyxia or apnoea has already been noticed as an element of 
disease (§ 234), and its nature and symptoms were then examined 
(§ 235) ; we here advert to it as a mode of death. By death begin- 
ning at the breathing apj^ratus, I mean that in which the function of 
the apparatus is the first to fail. In this respect it is distinguished 
from death beginning at the brain or medulla, which destroys by 
secondarily suspending the function of breathing, and the distinction 
is useful for practical purposes as serving to direct attention to the 
most suffering organ. Death by simple apnoea takes place in diseases 
of the lungs and air-tubes, in which the entrance of air to the lungs is 
impeded by effusion into the air-cells or tubes ; or by pressure upon 
them, as in bronchitis, pneumonia, pleurisy, &c. ; by obstruction to the 
passage of the air through the trachea or larynx, as in croup, laryn- 
gitis, and tumors or spasm constricting these tubes; or in circumstances 
mechanically excluding the passage of air by the mouth and nostrils, as 
in smothering, strangling, hanging, and drowning. 

The symptoms of the approach of this mode of death are — increas- 
ing feeling of suffocation or want of breath, which becomes most dis- 
tressing and agonizing as the want is unappeased; the efforts at 
respiration are made in a hurried and forced manner; the face, neck, 
and other parts of the surface become congested in proportion to the 
violence of these efforts ; and as these efforts are unsuccessful, the 
color of the congested parts changes from red to purple, and from 
purple to livid. The influence of this congestion and partial circulation 
of black blood (§ 235), is soon evident on the functions, causing stupor, 
reduction of temperature, weak and irregular pulse, rapid reduction of 
muscular strength, and consequently of the efforts to breathe. Hence 
the dark hue of the face may be changed to paleness; but the lividity 
of the lips, tongue, nails, and other colored parts, remains until death. 
In cases of speedy death from violence, as hanging, drowning, &c., or 
from a sudden attack of laryngitis or spasm, the respiratory efforts 
are more vigorous, and the congestion and lividity of the surface are 
greater, and may remain until death. But in the slower asphyxia from 
diseases of the lungs and air-tubes, the interruption to the breathing is 
less complete, the efforts are less violent, the congestion of the surface 
is less marked, and the functions more gradually failing together, the 
symptoms peculiar to apnoea are less decided. Hence, too, as imper- 
fectly arterialized blood is circulated throughout the body, it may cause 
peculiar symptoms, such as stupor and low delirium, partial paralysis, 
vomiting, relaxation of the sphincters, and other symptoms of slink- 
ing. This exemplifies what has been before remarked (§ 622), that 
the distinctness of each mode of death generally depends on its speedy 
supervention. 

As prognostic signs, the symptoms of apnoea are more hopeless in 
proportion as they are conjoined with those of debility. The nature 
of the obstruction to the respiration must of necessity be taken into 
account ; and if this be not complete and irremovable, the congestion 



412 PROGNOSIS. 

and livicllty of the surface are not fatal signs, so long as the strength 
of the breathing apparatus and of the heart does not decline ; as this 
becomes exhausted, the means of recovery are lost. 

628. Death by coma, or beginning at the brain, is caused by various 
influences which primarily destroy the functions of the superior masses 
of the nervous system. The chief of these circumstances are obstruc- 
tion to the circulation through the brain by pressure (as of effused 
blood, pus, lymph, or serum, or of distended vessels in apoplexy, a 
depressed portion of bone in fractured skull, &c. ;) by coagula within 
the vessels in ansemia (§ 267); and by various narcotic poisons, such 
as opium, alcohol in large quantities, carbonic acid or ether vapor 
inhaled (§§ 128, 246), and sometimes the excrementitious matter of 
urine and of bile in the blood (§ 249). 

The symptoms of coma are those of interrupted function of the brain, 
insensibility and suspension of voluntary motion, the heart's action not 
being materially impaired. These may come on in different modes. In 
apoplexy and injuries of the head they may supervene suddenly, and 
the patient at once becomes powerless and senseless, the pulse continues 
pretty good, although slower and fuller than usual, or it may be frequent 
from mere sympathy. In other cases, the stupor comes on gradually, 
and the senses and mental powers are often irregularly obscured, caus- 
ing dimness of sight, appearances of clouds or cobwebs before the 
eyes, muscse volitantes ; various imperfections of hearing, with noises, 
or tinnitus aurium ; numbness and tingling sensations in the limbs ; 
loss of memory, confusion of ideas, hallucinations, low delirium alter- 
nated with stupor [typhomania)^ continued somnolency, &c. Partial 
paralysis often accompanies progressively advancing coma, sometimes 
of the lower extremities (paraplegia)^ more commonly of one side 
{hemiplegia). In the operation of narcotics, the state of coma is com- 
monly preceded by symptoms of cerebral excitement, manifest in the 
usual signs of intoxication and delirium, which vary in the case of 
different poisons. For these particulars, I must refer to works on 
toxicology and materia medica. 

In conjunction with these symptoms, referable to the sensorial and 
voluntary functions, there are often symptoms of various affections of 
the excito-motory system of the medulla ; at first, they are those of 
excitement, such as convulsion, vomiting, hiccough, contracted pupil, &c. 
(§ lo2). Thus, the coma of apoplexy, and sometimes the stupor of 
narcotism, are occasionally accompanied by convulsions (§ 150), general 
or local ; and I have elsewhere (§ 153) endeavored to explain how 
these opposite effects on different parts of the nervous centres may 
arise from the same cause. But in cases of more extreme coma, the 
excito-motory power of involuntary motions becomes impaired, the 
breathing is stertorous and imperfect, the actions of coughing and ex- 
pectoration arc not eusily excited, deglutition becomes impossible, the 
pupils are not dilated, emetics fail to excite vomiting, the sphincters 
arc relaxed, and involuntary discharges of urine and feces take place. 
']1jo last group of symptoms was' before noticed as the fatal part of 
coina and narcotism (§ 154). 

It is a question whether the functions of the brain can be completely 



MODES OF DEATH — BY COMA. 413 

suspended for any length of time without those of the medulla suffer- 
ing also. During common sleep there is not complete insensibility or 
suspension of volition, for movements are then made in consequence 
of unpleasant sensations, yet without the sleep being broken. It is 
probable that in the trance of nervous subjects, of hysteric coma 
(§ 141), neither sensation nor volition is entirely abolished ; but it is 
difficult to ascertain the truth in these cases, for the patients often 
deceive themselves as well as others. But in the heavy sleep of intoxi- 
cation, and in the stupor of coma, in which pinching scarcely excites 
any evidence of consciousness, the functions of the medulla seem to be 
also impaired, for the breathing is slow and stertorous, and irritations 
of the nose and eyes less readily than usual excite the motions of 
sneezing and winking. It is in proportion as these functions are im- 
paired that coma becomes dangerous ; and it is because they are not 
impaired (and in some instances are distinctly augmented as manifest 
by the sighing and spasmodic twitching that occur) in nervous or 
hysteric stupor, that this is unattended with danger. It appears pro- 
bable, however, that coma, when complete, may cause death by the 
abolition of sensation only, and if so, we are warranted in distinguishing 
between death by coma and death by paralysis of the medulla. Although 
the movements of breathing are ordinarily independent of the con- 
sciousness or will, yet such is not the case of the extraordinary move- 
ments which commonly take place in a deep breath or sighing ; when 
the ordinary action is impeded by posture, fatigue, exhaustion or any 
other debilitating cause. Under these circumstances, when the function 
of the brain is unimpaired, the feeling of want of breath arouses a 
succession of voluntary efforts, which are manifest in suspirious breath- 
ing, and which are the cause of sleeplessness in delirium tremens, and 
other states of exhaustion (§ 154). But when sensibility and voluntary 
power are wholly suspended, these supplementary efforts are not made ; 
for want of them, the respiration is insufficiently performed, and the 
lungs and air-tubes gradually become congested; this congestion and 
the resulting secretion farther impair the involuntary part of the pro- 
cess of respiration, and thus, without any indications of paralysis of 
the medulla, the signs and effects of apnoea are slowly superinduced 
on the state of coma. Under such circumstances, it is of great im- 
portance to place the patient in such postures or other circumstances, 
as shall most favor the movements of breathing, and remove pulmonary 
congestion by the proper remedies, should it arise. 

Snoring arises from a relaxed state of the soft palate, and is of little 
moment so long as the movements of breathing are sufficiently strong 
and frequent ; but when the respiratory powers are impaired, stertor is 
not only a sign but a cause of obstruction to the passage of the air, and 
should be prevented as much as possible by changing the posture of the 
patient. 

The most dangerous kinds of coma, then, are those attended with 
symptoms of impaired excito-motory function, or those so profound and 
prolonged, as to deprive the respiration of all aid from voluntary efforts, 
the signs of danger being apparent especially in connection with the 
respiration. In apoplexy, contraction of the pupil of one or both eyes 



414 PROGXOSIS. 

is of very unfavorable import, because it indicates an excitement of the 
upper portion of the medulla, Trhilst the brain is oppressed ; such a 
combination can only proceed from the partial operation of a clot in 
the substance of nervous centres, compressing one part and irritating 
another. 

629. That death should ensue from injured function of the medulla 
ohlongata and spinalis is quite intelligible, when it is considered that 
on this portion of the nervous system the ordinary act of breathing 
depends. This mode of death, like the last, is by apnoea ; but the 
death, or failure of function, here begins with the nervous link of the 
chain of actions constituting the process of respiration ; whereas in 
simple apnoea, it commences with the mechanism of the breathing appa- 
ratus. 

This death may be called death by fjaralysis^ and, as in other cases 
of paralysis of the excito-motory function (§ 144), it may be caused by 
suspended function, either of the nervous centre (medulla oblongata), 
or of the afferent nerves (par vagum and sympathetic), or of the efferent 
nerves (phrenic, intercostals, and spinal accessory), which complete the 
respiratory circle. Of influences which destroy the function of the 
medulla oblongata itself, may be mentioned, hemorrhagic effusion into 
its substance or upon it, fractures of the base of the skull, and any 
very considerable pressure on the whole encephalon. I have witnessed 
several deaths from encephalic hemorrhage, in which the stroke was 
not attended with loss of consciousness, and would not therefore be 
termed apoplectic, but paralytic, with loss of power of articulation, 
hemiplegia, and laborious and stertorous breathing which was obviously 
aided by voluntary efforts or struggles, the patient by gesticulations and 
violent gaspings, showing his consciousness of the failing respiration. 
In two such cases, in addition to some hemorrhage in one hemisphere 
of the brain, there was a clot in the pons Varolii. These cases esta- 
blish the truth of the distinction between the death by coma and death 
by paralysis. Some poisons also seem to affect the medulla more 
immediately than the brain. Thus, animals poisoned with woorara, 
essential oil of bitter almonds, conia, belladonna, and perhaps some 
other poisons, are affected with gasping and other signs of impaired 
function of respiration before they lose consciousness ; {Recording to the 
experiments of Sir B. Brodie and others, they die simply from suspen- 
sion of respiration, and if this process be artificially maintained for a 
time, the animals may sometimes recover from the effects of the poison. 
The same remark in some degree applies to opium and its active princi- 
ple, but less distinctly, for these early induce coma, and often impair 
tlie action of the heart also. Experiments are wanting to establish 
tliG elementary operation of this and other poisons, as the functions 
arc now viewed by pliysiologists. In some cases in which I have seen 
animals die from rapid hemonliage, tlie respiration has ceased for some 
seconds before the heart's action ; and from the peculiarly labored state 
of the breathing, and late retention of consciousness, I conclude that 
death from hemorrhage, in some instances at least, is due to suspension 
of the function of the medulla. 



MODES OP DEATH — BY PARALYSIS. 415 

630. The division of the eighth nerves in the neck in animals illus- 
trates one mode of inducing death by paralysis. These are the chief 
incident or afferent nerves from the lungs to the medulla, transmitting 
the impressions which excite the motory nerves of the muscles of respi- 
ration. When they are divided, the breathing is imperfectly performed, 
and expectoration and cough cannot take place ; apnoea, therefore, gra- 
dually follows. Although we have not a result to the same amount ex- 
hibited in disease, yet we have an approach to it in the dyspnoea, some- 
times constant, sometimes in paroxysms, caused by pressure of tumors 
on these nerves, or by malignant disease involving them. 

631. The third mode in which the nervous link of respiration may 
be broken by injury to the excito-motory column of the spinal marrow 
or its branches, is exemplified in the case of breaking the neck, or 
dislocation of the upper cervical vertebras. Pithing an animal effects 
the same thing. All parts supplied by nerves from below the injured 
portion of the medulla become paralyzed, and therefore their motions 
cease. Diseases in the vertebras, in the spinal cord, or in its mem- 
branes, have been followed by similar results ; and the functions of the 
several nerves of respiration are illustrated by these cases. I have 
known disease affecting the cord at the upper cervical vertebrae cause 
loss of motion in all parts below the neck except the diaphragm, v/hich 
is supplied by the phrenic nerve, and through which for awhile respi- 
ration was wholly carried on. The patient afterwards regained power 
in the spinal accessory nerve, by which he was enabled to elevate the 
Tipper part of the chest ; and subsequently some power was for a time 
restored to the superior intercostal nerves and muscles.^ In other 
cases, diseases of the spinal cord creeps from below upwards beginning 
with paralysis of the lower extremities and pelvis, then reaching the 
dorsal spine, palsying the intercostals, and at last reaching the neck. 
The advance or retrogression of all these symptoms are of great im- 
portance in the prognosis of such diseases. 

632. Besides the respiratory functions, the functions connected with 
excretion are dependent on the integrity of the spinal cord ; they fail 
when it is seriously injured, and this failure may furnish symptoms of 
death, beginning at the spinal cord. When the cord is injured only at 
a point, and remains healthy above and below it, the injury may 
merely intercept the transmission of sensation upwards, or of volition 
downwards beyond the injured point. Hence, there may be loss of 
sensation, or of voluntary motion, or of both, in the lower portions of 
the body. If this reach the urinary apparatus, the power of sponta- 
neously voiding urine is lost. But the reflex or independent excito- 
motory influence of the spinal cord remains ; hence, the sphincters and 
the bladder retain their power, and when the catheter is introduced 
into the bladder, it contracts as usual, aided by the voluntary power 
remaining in the diaphragm and abdominal muscles. We have before ' 
noticed (§ 149) that, under these circumstances, the muscles of the 
lower extremities retain and accumulate their irritability, and although 
the will has no command over them, yet tickling, or even touching 

1 Med.-Chir. Trans. 1843. 



416 PROGNOSIS. 

them, may excite them to contract with unwonted energy (§ 141). The 
exercise thus kept up seems to be sufficient to preserve their nutrition, 
for they do not waste away. 

But it is quite different if the spinal cord he extensively injured, as 
by crushing, softening, or a considerable effusion of blood or pus into 
its sheath. Its function then ceases, not only as a communicator of 
sensation and voluntary power to the lower parts of the body, but also 
as a source of that involuntary excito-motory power by which the 
sphincters contract and the urinary bladder evacuates its contents. 
Hence, there is constant dribbling of urine, yet without the power com- 
pletely to empty the bladder. The feces are discharged unconsciously, 
and without the power of control. The limbs are not only insensible 
and powerless to the will, but their muscles can no longer be excited 
by tickling; they lose all motion, and the bloodvessels lose that influ- 
ence which the nerves of all orders exercise upon them. It is not 
surprising, under such circumstances, that the death which has begun 
in the spinal cord should spread to the parts whose functions it can no 
longer maintain. The urine, imperfectly discharged, putrefies, and 
causes inflammation of the bladder, which may gradually extend to 
and stop the function of the kidneys. The intestines become dis- 
tended and obstructed with gas and pent-up feces. The limbs lose 
their proper circulation for want of motion and nervous influence in 
their muscles and vessels ; their nutrition fails, they become oedema- 
tous, partially inflamed, livid, and run into gangrene ; and all these 
changes are so many signs of the progress of death which has begun 
in the spinal cord. 

From the remarkable effect of cold and some poisons on some of 
the lower animals, inducing paralysis of the hinder extremities, it is 
probable that these agents are capable of especially injuring the func- 
tion of the spinal cord, beginning with the remote part. Has the 
gangrene of the lower extremities, sometimes induced by the use of 
ergotted corn, any connection with an injured function of the spinal 
cord ? 

Death of the medulla supervenes on that beginning with coma and 
asthenia in many cases; and as its involuntary excito-motory function 
is the guardian of many processes essential to life, the symptoms con- 
nected with it are of great importance in connection with prognosis. 
(See § 154.) 

633. Necrsemia^ or death heginning with the bloody are terms which 
I venture to give to those fatal cases in which the chief and most re- 
markable change is exhibited by the blood. In typhoid fevers and 
others of the malignant or pestilential kind (§ 105), none of the solids 
of the body constantly exhibit such an early change of function or of 
structures, as would warrant us in tracing disease and death to them. 
It is true, that the functions of many solids are impaired — the muscular 
and nervous systems, secretion, digestion, assimilation, and nutrition, 
all suffer, but the very universality of the affection seems itself to point 
to some cause more general than can be found in any individual func- 



MODES OF DEATH — BY NECR^MIA. 417 

tion ; and such a cause may be found in the blood. The blood, at an 
early period of these diseases, when they occur in their worst form, 
exhibits changes which show that disorder begins with it, and this 
disorder may reach to a fatal degree. The appearance of petechise 
and vibices on the external surface, the occurrence of more extensive 
hemorrhages in internal parts, the general fluidity of the blood (§ 196), 
and frequently its unusually dark or otherwise altered aspect (§ 186), 
its poisonous properties as exhibited in its deleterious operation on 
other animals (§ 259), and its proneness to pass into decomposition, 
point out the blood as the first seat of disorder, and by the failure of 
its natural properties and functions as the vivifier of all structure and 
function (§§ 182, 263), it is plainly the medium by which death begins 
in the body. How far the change in the blood is in its structure 
(§ 189) and vital properties (§ 211), or in its chemical composition (§ 181), 
farther research alone can determine; the vivifying function of the 
blood depends on all these combined, and it is this function which 
obviously fails. Hence, the complete adynamia, or general prostration 
of all living powers, which occurs where this cause of death is most 
powerful. The blood, the natural source of life to the whole body, is 
itself dead, and spreads death instead of life. Almost simultaneously, 
the heart loses its power, the pulse becoming very weak, frequent, and 
unsteady; the vessels lose their tone, especially the capillaries of the 
most vascular organs, and congestions occur to a great amount (§§ 290, 
293) ; the brain becomes inactive, and stupor ensues ; the medulla is 
torpid, and the powers of respiration and excretion are imperfect ; 
voluntary motion is almost suspended ; secretions fail ; molecular nu- 
trition ceases ; and at a rate much more early than in other modes of 
death, molecular death follows close on somatic death — that is, struc- 
tures die and begin to run into decomposition as soon as the pulse and 
breath have ceased; nay, a partial change of this kind may even 
precede the death of the whole body (somatic death — Dr. Pritchard);^ 
and the fetid aphthous patches in the throat, the offensive colliquative 
diarrhoea of persons in the last stage of various fatal diseases ; parts 
running into gangrene, as in the carbuncle of plague, the sphacelous 
throat of malignant scarlatina, and the sloughy sores of the worst 
forms of typhus, and in the large intestines in dysentery, and the 
putrid odor exhaled even before death^ by the bodies of those w^ho are 

'' See Dr. Symond's interesting essay on "Death," in the Cyclopsedia of Anatomy and 
Physiology. 

2 Certain anecdotes, usually considered to be superstitious, derive some probability 
from the above-mentioned facts. It is said that some of the lower animals, especially 
dogs and rats, have an instinctive foreknowledge of the approach of death in a house. 
I have known two instances, in which for two days before a death and until the body 
was removed from the house, rats from the drains infested the basement of the house in 
a degree never approached before or since. It is possible that a deathy odor [of which 
some sensitive persons profess themselves conscious] may be perceptible to the acute 
olfactory organs of these animals ; or perhaps a more substantial cause of attraction may 
be presented in the putrid excremeutitious discharges thrown down the drains under 
these circumstances; and this notion may give some countenance to the still more 
marvellous assertions generally made by sailors, that sharks will pertinaciously follow 
a ship that bears a dying man or corpse. 

27 



418 PROGNOSIS. 

the victims of similar pestilential diseases — are so many proofs of the 
early triumph of dead over vital chemistry. 

634. "We have hitherto represented an extreme case ; but there are 
many lower degrees in which disease begins with the blood, and various 
disturbances and reactions result. The causes which appear thus pri- 
marily to affect the blood are especially endemic, epidemic, and infec- 
tious influences, called poisons (§§ 81, 88, 93), certain animal and 
vegetable poisons, as that of the most venomous reptiles and fungi, and 
probably some mineral poisons, as sulphuretted hydrogen, selenium, and, 
in part of its operation, arsenic. The direct influence of all these agents 
is depressing (§ 105), and when they operate in large quantities, or in a 
concentrated form, the vital powers fall quickly into a state of adynamia 
or prostration, which soon ends in death, as we have already described 
it, the blood first and most constantly manifesting a change. Eut if the 
noxious influence is in smaller quantity, or more diluted, the vital powers 
react against it (§ 16) in various ways, the object of which can often be 
plainly discerned to be its expulsion from the system. The shivering, 
hot stage, and sweating termination of paroxysms of intermittent fever; 
the similar but less marked series of febrile movement which occur in 
slight forms of remittent and continued fevers; the profuse and violent 
fluxes from the stomach and intestines in cholera, dysentery, and epi- 
demic diarrhoea, and the similar discharges induced by poisonous ingesta, 
are instances of the operation of vital reaction attempting the expulsion 
of the noxious matter, and of that part of the animal fluids that had 
been corrupted by it. But these struggles in many instances constitute 
serious diseases, in which life may be compromised by the violence and 
exhausting efi'ect of the reaction as much as by the prostrating influence 
of the cause of the disease; in these more complex afi"ections, individual 
organs may especially suff'er in different cases, and the danger and cause 
of death may be less in the changed condition of the blood than in the 
afi'ections of particular organs, or the exhaustion consequent upon them, 
which destroy, not by necrsemia, but by coma, asphyxia, or asthenia, 
modes of death already considered. 

635. The injurious efi'ect of these poisons may be still more com- 
pletely prevented when their quantity is small and the living powers are 
vigorous. A diarrhoea, a profuse sweat, or a free flow of urine, some- 
times carries off" the commencing disease. The intestines, the skin, and 
the kidneys, appear to be the proper emunctories through which morbid 
matter is expelled. The peculiar fetor of the secretions from the bowels 
in typhoid fever, the beneficial influence of moderate, diarrhoea, which 
removes them in the early stage of fever, and appearance of afoul fibrin- 
ous matter (typhus-material of German writers), in theintestinal glands, 
seem to be examples of the elimination of a morbific matter; and 1 have 
before suggested (§ 404, note), that the follicular inflammation, ulcera- 
tion, and sloughing of the intestines in fever may arise from the exces- 
sive irritation of tlie follicles in the exercise of this eliminating function. 
Again, with regard to the kidneys, it has been before mentioned, that 
granular degeneration, which impairs their function and power of elimi- 
nation, renders the body peculiarly liable to contract epidemic and 



MODES OF DEATH — BY NECRiEMIA. 419 

infectious diseases, and to succumb under them (§ 260).^ This renders 
the prognosis unusually unfavorable in these cases. The same remark 
extends and for the same reasons, to persons who have been habitually 
intemperate. On the other hand, those whose kidneys are naturally 
active, more effectually resist disease, and more readily throw off its 
effects (§ 448). In like manner, it is well known that persons with a 
naturally dry skin do not so readily get rid of a fever as those in whom 
perspiration is readily excited. 

636. Besides the influences already mentioned (§ 634), as first attack- 
ing the blood, and in extreme cases injuring its composition and causing 
its death, there are others originating in the body itself. Thus the pro- 
cesses of gangrene and suppuration sometimes infect the blood with a 
septic poison (§§ 470, 475), and cause death in a manner and with symp- 
toms like those of the poisons above noticed. The sudden suppression 
of the excretions of urine or bile, from disease, or under the influence of 
any severe shock, also seem in some cases to operate by injuring the 
properties of the blood ; whilst in other instances it distinctly induces 
coma or asthenia. We have before adverted to retention of excremen- 
titious matter as a cause of caehsemia^ or depraved state of the blood 
(§§ 249, 564) ; so we now find that, in an extreme degree, it may cause 
necrsemia^ or death of the blood. 

637. The symptoms which should make us apprehend the approach 
of death by necrsemia may be gathered from the preceding descriptions. 
Those symptoms generally called typhoid, putrid, or malignant, belong 
especially to this class of deadly influences. For example : a congested 
appearance of the whole surface, the color being dusky or livid, and 
extending to the conjunctiva, tongue, and fauces ; various slight ex- 
anthematous or papular patches on the skin, often with petechias; 
more extensive hemorrhages in form of ecchymoses, or oozing of thin 
bloody fluid from the gums, nostrils, and sometimes from other pas- 
sages; extreme prostration of strength, with an obtuse state of all the 
senses and mental faculties, sometimes combined with delirium and 
twitchings of the limbs ; half-closed eyes and dilated pupils ; a very 
frequent, weak, and soft pulse ; frequent and unequal respiration ; no 
appetite ; intense thirst, a dry, brown tongue, with dark sordes on the 
lips and teeth; a progressive fall of temperature, which may have been 
elevated at first; often cold, clammy, and fetid perspiration; hic- 
cough ; subsultus tendinum ; scanty, offensive urine ; involuntary dis- 
charges. 

Some diseases of the same class are modified by peculiar effects. 
Thus in malignant cholera, excessive discharges of serum, by vomiting 
and by stool, reduce the blood to such a spissitude, that it will no 
longer circulate through the vessels ; the pulse ceases, and the surface 
becomes blue and cold from the darkness and stagnation of the blood, 
and shrunk from the exhaustion of its fluids. In yellow fever, altered 

^ This was exemplified in the case of an epidemic erysipelatous angina, which attacked 
several patients of the Uniyersity College Hospital, in the spring of 1843. Out of about a 
dozen cases in which persons affected with various diseases were attacked, three died from 
the erysipelas extending to the larynx, and in all these the kidneys were granuLir and the 
urine albuminous. 



420 



PROGNOSIS, 



blood is ejected from the stomacli in the form of what is called black 
vomit. But to pursue this subject into farther details belongs rather 
to the department of special pathology. 

63!:^. It has been before mentioned, that the complete distinction 
of these different modes of death is almost exclusively confined to 
cases of speedy or sudden death. In the slower dissolution, by which 
diseases generally prove fatal, all functions and structures are more or 
less involved; and the life in all is dwindled down to so slight a thread, 
that when it breaks in one, others scarcely retain it long enough to 
enable us to say that death begins distinctly in any part. 

[A brief sketch of some of the most common symptoms influencing 
our prognosis, will not, perhaps, be here without value. 

Much may be inferred from the general aspect of the patient. Con- 
stant change of position, unimportant in the beginning of acute dis- 
eases, becomes alarming when it persists for any time. Lying con- 
tinually in the same position, as constant dorsal decubitus, in low^ forms 
of disease, is a very bad symptom. Inability to lie down, which some- 
times happens in thoracic disease, is equally sinister. Jactitation suc- 
ceeding to quietude, in the latter stage of acute disorders, is generally 
a mortal sign, especially when accompanied by an attempt to throw 
aside the bedclothes, and ineifectual eiforts to rise. 

Progressive emaciation in acute affections is of little importance, but 
in chronic disorders it should lead us to anticipate a fatal termination 
in proportion to its rapidity. General oedema is of extremely bad 
augury. The occurrence of sloughs in various parts of the body, in 
both chronic and acute disorders, is a very bad sign. The physiog- 
nomy should be especially studied in reference to prognosis. When the 
natural expression of the countenance is preserved, it is always of fa- 
vorable import. Great alteration in the features in the commencement 
of an acute disorder, ought to make us fear, about the fifth or ninth 
day, the supervention of \ovi symptoms. In the advanced stage of all 
diseases, a sudden and great alteration in the physiognomy announces 
approaching dissolution. When it occurs at a period where a fatal 
termination is not to be anticipated, it should lead us to suspect the 
development of some acute affection, the enfeebled state of the patient 
not admitting of its exhibiting the ordinary local symptoms ; a sudden 
aggravation of the general symptoms being the only indication. It 
generally announces death in less than three days. This change of 
countenance must not be confounded with the pallor which marks the 
commencement of convalescence in fever, etc.; the accompanying phe- 
nomena serve to distinguish them. Subsultus, trembling, and rigidity, 
always mark danger. Carphologia, epileptic and tetanic convulsions, 
rigidity of the limbs, arc mortal signs in the advanced stages of fever. 
Another invariably fatal symptom, according to Chomel, is the auto- 
matic movement by which the patient seeks to approach his hand to 
his body, whilst the physician is feeling his pulse. Aphonia is a bad 
sign in acute disorders. The intensity of pain, by no means, in gene- 
ral, indicates the amount of danger. Cwteris paribus, deep-seated pain 
is more unfavorable than that which is superficial; and that which is 



PRoaxosis. 421 

fixed more so than that which is variable. The sudden cessation of 
pain in inflammation, joined to great alteration in the features, indicates 
approaching death. According to Chomel, suppuration, not gangrene 
will be found, under such circumstances, on examination. Deafness 
is a sympathetic phenomenon occurring in many acute diseases, and is 
always serious. In the mortality of typhoid fever, if a comparison be 
made of those who suffered from deafness in the course of the disease 
and those who did not, the deaths among the former will be found as 
two to one among the latter (Chomel). Hope and cheerfulness are 
generally good signs. Distrust and despair are very unfavorable symp- 
toms. It is rarely that patients who have the persuasion that they 
will die, recover, unless they are hypochondriacs. Total indifference 
is a bad sign. In several chronic disorders, the tranquil security en- 
joyed by patients does not diminish the gravity of the prognosis. 

The prognostic signs furnished by delirium are connected with its 
intensity, persistence, and the conditions under which it occurs. Mild 
delirium, soon passing off, is not serious ; permanent delirium always is. 
Many persons, of all ages, are liable to delirium whenever they are 
attacked with ephemeral fever, or an angina ; it is only necessary to 
be aware of the idiosyncrasy in order to appreciate the value of the 
symptom. 

Prolonged sleep in the course of fevers is not dangerous if the pa- 
tient be readily aroused. Coma is alarming and nearly always mortal, 
when intense and permanent. 

The sudden occurrence of a voracious appetite announces speedy 
death (Baglivi). Chomel has frequently met with this symptom in 
pneumonia ; death soon took place. Dysphagia is generally a mortal 
symptom in cerebral and acute disorders. 

The signs which the respiration furnishes prognosis are important 
and rarely deceive. A hurried respiration indicates great danger. 
When the number of respirations amounts to fifty in the minute, it may 
be generally stated that death will soon follow. The tracheal rattle 
and stertorous breathing are usually precursors of dissolution, espe- 
cially when they occur towards the latter stages of cerebral disease. In 
inflammation of the lungs stertor is not alarming so long as expectoration 
takes place. Paroxysmal is less dangerous than permanent dyspnoea. 
Hiccough is a very unfavorable symptom in the latter stages of disease, 
unless it is accompanied by a notable amendment in the other symp- 
toms. 

The pulse furnishes few but important symptoms. A pulse of mode- 
rate frequency and force is favorable. Considerable frequency of 
pulse indicates something serious. A pulse of 150 in an adult should 
lead to a very unfavorable prognosis. If at an advanced period of any 
affection the pulse becomes irregular or intermittent, or ceases, death 
is near. 

Augmentation of the heat of the body is of bad import, especially 
when dry. Sudden chilliness of the extremities and rest of the body 
occurs usually a short time previous to dissolution. Chills at an ad- 
vanced period of the disease, should lead to the suspicion of the form- 
ation of pus, or of its resorption, according to circumstances. Abund- 



422 



PROGNOSIS. 



ant sweating towards the close of a disease is a favorable sign. Cold 
sweats at the same period are generally unfavorable. 

Hemorrhages at the beginning indicate usually that the disorder will 
be serious. Towards the close they are either favorable or unfavorable. 
Epistaxis, the hemorrhoidal flux, and metorrhagia, are generally favor- 
able signs in those who are liable to them. Hemorrhages from the 
lungs and intestines are usually mortal ; those from the urinary organs 
nearly constantly fatal. 

The degree of strength which the patient possesses is of great im- 
portance in forming a prognosis ; considerable diminution or perversion 
is always dangerous, especially in the early stage of the disease. — C] 



is 



ii 



CHAPTER YII. 

PROPHYLAXIS AND HYGIENICS. 

639. Prophylaxis is the guarding against a particular disease ; and 
hygienics relate to the prevention of diseases in general, or to the pre- 
servation of health. The former is connected with special rather than 
with general pathology; and it should be founded on a due knowledge 
of the causes, nature, and tendencies of diseases, and of the various 
means in diet, regimen, residence, and medicine, which are capable of 
removing the causes of disease, or of preventing or counteracting their 
operation. 

640. Hygienics^' consist in the knowledge and application of those 
means, by which the structures and functions of the body may be kept 
in that normal state which conduces to their continued welfare — that 
is, in health (§ 6). We have found, that both structures and functions 
have the elements of disease in themselves, when anything disturbs 
their due proportion. We have noticed the circumstances which lead to 
such disturbance, both in connection with the causes of disease (under 
the head Etiology), and in connection with its intimate nature (in the 
division Pathology propej^) ; and remarks on the medicinal and hygienic 
means of preventing or counteracting those circumstances were intro- 
duced in the context to a sufficient extent to suggest the principles of 
hygienics. It will be sufficient in this place to consider briefly the 
chief corresponding circumstances which promote the maintenance of 
health, and these may be arranged under the following heads: Food ; 
Clothing ; Temperature; Air; Exercise; 3Iental Occupation; Sleep ^ 
and Excretion. The nature of this work precludes many details on 
these important topics, and the following is intended as a mere outline 
in conformity with the principles previously explained. 

[The object of hygiene is the preservation of health and the preven- 
tion of disease ; and hygienics include everything which tends to ac- 
complish these ends. Although hygiene has been called the medicine 
of healthy individuals, it is still applicable and even indispensable to in- 
valids, and is often of more service to them than medicine itself; for whilst 
the efficacy of many remedies may be doubtful, the propriety of hygi- 
enic measures is universally admitted. By their aid alone, without a 
resort to the materia medica, the majority of acute disorders will ter- 
minate favorably ; without them our best directed efforts will often prove 

^ I use this term (derived from the Qv^Qkhyinvino;, relating to health, aud analogous to 
optics, acoustics, &:c.) as more conformable to our language than the French term hygiene. 



424 HYGIENICS. 

unavailiDg. ^\e frequently see patients in bad hygienic conditions, 
perish in spite of able physicians, and an abundance of remedies, and 
the mildest diseases converted into mortal ones from similar reasons. 
The crowding of patients into narrow, ill-ventilated places, the contami- 
nation of the air, the absence of cleanliness, the want of suitable cloth- 
ing, exposure to cold and wet, errors of diet, mental depression, fatigue 
collectively, invariably produce terrible effects; whilst in a large num- 
ber of acute affections of the severest kind, recovery occurs without a 
resort to any active remedy, merely under general hygienic measures. 
-C] 

FOOD. 

641. The purpose of food being the supply of materials, which, w^hen 
prepared by the process of digestion, shall repair the waste of the body 
and maintain its temperature, it is obvious that this purpose will be best 
fulfilled when the materials supplied are of such quality and quantity, 
and so administered, as to suit respectively the powers of digestion and 
the w^ants of the system for nourishment and warmth; in other words, 
food should be digestible, nutritious, and calefacient, and the articles 
which duly comprise all these qualities will be the most wholesome 
food. 

642. The importance of a due combination of the chief alimentary 
principles, albumen, oil, sugar, or starch, with water as their diluent, 
has been before pointed out (§ 58); and the expediency of preferring 
such materials as comprise these in the best quality or condition may 
also be inferred from preceding observations (§ 60). 

[A diet exclusively animal produces constant stimulation of the ali- 
mentary canal, augments thirst, and is accompanied by constipation ; 
the alvine excretions being hard, dark colored, and small in quantity. 
The natural temperature of the skin is augmented, the pulse is in 
general frequent and quick, and there is emaciation. The blood is 
modified by a diminution in its aqueous constituents, whilst the propor- 
tion of globules and of fibrine is increased. The urine is scanty, con- 
tains much solid matter, is somewhat dark colored, and very acid ; being 
highly charged with urea and uric acid. This regimen is adopted by the 
inhabitants of cold climates, and those who are particularly addicted 
to violent muscular exercise. It is thought to generate the requisite 
amount of animal heat to enable them to resist a very low temperature. 
Such a regimen in temperate climates, if long continued, causes inflam- 
matory disorders, w^liich the increase in the amount of fibrine in the 
blood adequately accounts for. 

A diet exclusively vegetable is certainly less injurious to health, and 
this result is probably due to most vegetables containing nitrogenized 
matters, as vegetable fibi"inc, albumen, and cascine. If a regimen ex- 
clusively vegetable be continued for any length of time, it invariably 
causes a languid and feeble state of the digestive system ; the act of 
digestion being protracted and painful, and accompanied or followed 
by the development of gas. The feces are abundant, light-colored, 
often scmiliquid, and diarrhtt^a is not infrequent. The temperature of 



FOOD. 425 

the body is low, and easily falls ; the constitution is feeble, and there 
is but little bodily vigor. During the use of an exclusive and abundant 
vegetable diet, obesity is very apt to be developed, especially if but 
little exercise is taken. Many disorders may be developed as the con- 
sequence of such a regimen. 1. By the impoverishment of the blood, 
from the simultaneous and proportional diminution of the red globules, 
albumen, and fibrine, anaemia or dropsy may follow. 2. Gastralgia, 
flatulent dyspepsia, diarrhoea, &c. 3. Entozoa are often the conse- 
quence of vegetable aliment in excess. 4. Diabetes is generally regarded 
as one of the results of the exclusive use of fecula ; the large quantity 
of sugar produced by the liver not being burnt by the oxygen absorbed in 
the act of respiration, a portion passing unchanged into the arterial 
current, from which it is excreted by the kidneys. 

A mixed diet, composed of a moderate and determined quantity of 
animal and vegetable substances is that best adapted to the inhabitant 
of temperate climates. According to M. Dumas, a man in good health, 
and of ordinary appetite, should consume in the 24 hours 154 grammes 
of carbon, and 225 of nitrogen; the following quantity of corresponding 
articles of food he proposes for a cavalry soldier. 



Fresh meat 
Camp bread 
White bread 
Vegetables 



Weight. 


Nitro 


g. matter. 


Non-nitrog. matter 


Grains. 




Dry. 


Dry. 


125 




70 




750 \ 
516/ 




64 


595 


200 




20 


150 



1591 154 745 



The proportions of nitrogen contained in different vegetables may be 
represented, according to M. Boussingault (the quantity of this prin- 
ciple contained in wheaten flour being 100), by the following equiva- 
lents : rice 77, peas 67, lentils 57, beans 56. — C] 

It may not be superfluous to exemplify these points farther by a few 
comments on common articles of diet. 

Wheaten bread comprehends the albuminous (gluten) and the amyla- 
ceous principle, and only needs the addition of butter to complete the 
requisite combination for moderate nutrition. The goodness of bread 
depends not only on the character of the grain from which the flour is 
obtained, but also on the mode and degree of its fermentation and bak- 
ing. If fermented with leaven instead of yeast, or if overfermented, 
acetic acid is generated and the bread is sour, and this is the common 
fault of bread in large towns where the supply of yeast is insufiicient, 
and it prevails universally on the Continent. This evil is avoided in 
the unfermented bread, which is rendered porous by an eff"ervescence of 
carbonic acid gas, caused by an admixture of carbonate of soda with 
the flour, and hydrochloric acid with the water, of which the bread is 
made ; when well prepared such bread is veiry sweet and free from acid- 
ity, but unless carefully prepared is liable to be heavy, and like imper- 
fectly fermented bread it is then unflt for mastication. Bread insuffi- 
ciently baked is glutinous and indigestible, and much of the same 
objection applies to quite new bread which has not dispersed its moist- 
ure. These defects may in great measure be remedied by toasting the 



426 HTGIEXICS. 

bread in tliin slices, which has also the advantage of dispersing much 
of the acid from sour bread. Very white bread is objectionable as be- 
ing less nutritious (having less gluten) and more constipating than that 
made with less refined flour ; but the coarse material commonly sold 
as brown bread errs to an opposite extreme, in containing a bran so 
coarse as to be irritating to many stomachs. Good country bread fer- 
mented with yeast, and well baked, presents the kind most generally 
wholesome. 

"Meat comprises the albuminous, oily, and gelatinous principles, be- 
sides creatine and other soluble extractive matters, which are probably 
nutritious. It requires combination with vegetables or bread to make 
it suitable to the palate and stomach. The object of keeping and cook- 
ing meat is to make it so tender as to be easily softened by the gastric 
juice, and all processes which interfere with or go beyond this result, 
render meat less wholesome. Thus salting or pickling, keeping until 
it becomes tainted, or hardenino: it bv overcookino: or fast boiliue. 
which corrugates and toughens the fibre, are so many means of spoiling 
the meat for the purposes of digestion, and rendering much of its nutri- 
ment unavailable. The flesh of young adult animals presents the great- 
est amount of fibrinous nutriment; that of younger animals contains 
more gelatine and fat; and that of older age is tough from the preva- 
lence of fibrous textures, which being gelatinous are more serviceable 
for soups. The kinds of animal food vary much in their composition, 
even when the lean parts only are selected. Thus beef and pork con- 
tain a large proportion of fat: mutton somewhat less; veal still less: 
and in the flesh of fowl, game, and white fish, there is only a small 
amount. This afi"ords an explanation of the fact that the latter articles 
are the best suited to persons of weak stomach. But the proportion 
of creatine and colored extractive doubtless also determines the quality 
of the food: thus the flesh of hare, which contains much, is more heat- 
ing than that of chicken and whiting or sole, which may be taken as 
the representatives of the mildest form of solid animal nourishment. 
Soups and broths, when deprived of excess of fat, are very useful arti- 
cles of auxiliary nourishment in combination with solid food, but they 
are not substantial enough to supply a meal to a healthy person. E.g'ys 
and milk respectively, separately or combined, form light and nutri- 
tious articles of animal diet. They are rendered easier of digestion by 
being heated to about 180°, by which part of the albumen is slightly 
coagulated. Both eggs and milk contain a considerable amount of oil. 
which causes them, when taken too freely, to disagree with persons of 
bilious habit. So likewise, they are prone to speedy decay, and lose 
much of their wholesome nature, even in a day or two. In like man- 
ner, fresh butter is an excellent adjunct to bread and vegetable articles; 
but speedily becomes rancid and loses its salubrious properties. Cheese 
is a low form of proteine compound, which requires energetic digestive 
and assimilating powers to raise it to the higher standard of the mate- 
rial of the plasma of the blood; it is therefore wholly unfit for delicate 
persons and those of weak digestion. 

<^)leraceous and succulent vegetables and fruit are fit adjuncts to the 
more nutritious articles of food, which they serve to dilute: and by the 



FOOD. 427 

subacid and extractive matter which they contain, they promote the 
secretions, and thus tend to purify and cool the blood. In most instances 
they require to be thoroughly cooked to give them the state of soft- 
ness fit for the digestive process. 

643. The choice of food and the arrangement of hours for different 
meals must vary much according to the habits and necessary occupa- 
tions, as well as the strength and tastes of individuals ; but the follow- 
ing plan of diet, with some variations, will be found well suited to the 
majority of healthy adults. 

Breakfast at from eight to nine A. M., of bread or dry toast with a 
moderate quantity of butter. One or two new laid eggs, boiled three 
minutes and a half: or a little cold chicken or game, or even a mutton 
chop, may be added for those who use much bodily exertion. Beverage, 
one breakfast-cupful of cafe au lait ; that is, clear strong infusion of 
coifee with scalded milk, in proportion of one-third of the former to 
two-thirds of the milk. Cocoa, deprived of fat, or thin chocolate with 
milk may be substituted. 

Luncheon at from one to two P. M., may consist of a small basin of 
good shin of beef soup, with vermicelli, rice, or toasted bread in it. If 
meat have been taken at breakfast, a biscuit or piece of bread and but- 
ter, or small sandwich may suffice for luncheon ; wine and malt liquors 
are generally better avoided at this time, unless dinner be taken at this 
hour. 

Dinner at from five to seven p. m. (The latter hour is not recom- 
mended, but is often unavoidable.) Wholesome fresh meat and vege- 
tables, well but plainly cooked, served hot, carefully proportioned, pro- 
perly masticated ; varied from day to day, with simple additions of fish, 
and moderate quantities of farinaceous or fruit puddings. Highly 
seasoned dishes, pickles, salted and dried meats, rich and heavy pastry, 
and cheese, except as a mere relish, to be excluded from a table pro- 
fessing wholesomeness. Beverages : sound white wine (sherry or good 
Marsala, from one to three glasses), which is generally better mixed 
with water ; or sound Sauterne or Moselle unmixed. 

[In this country, particularly during the summer season, a small por- 
tion of sound claret, mixed or not with water, according to the habits 
and constitution of the individual, is a preferable beverage during din- 
ner, than the strong and stimulating Spanish wines, which may be bet- 
ter borne in the moister climate of Great Britain. — C] 

Those who use much exercise may substitute sound malt liquor, bit- 
ter ale being the lightest, and good porter or stout the more sustaining. 
Half a pint is generally as much as is good for the health. Many 
thrive well, especially in the country, without any fermented liquor. 
If water is taken it should be in moderation, otherwise it may inter- 
rupt digestion. Some find warm water, or milk and water a pleasant 
beverage. The habit of taking wine after dinner is one of luxury, not 
of health, and all that can be said of it in hygienic instructions, is — 
the less the better. The practice of taking a little fruit at the same 
time is not equally hurtful, provided by its quality or quantity it do not 
excite indigestion. 

[A small cup of a strong infusion of coffee, without the addition of 



428 HYGIENICS. 

milk or cream, taken immediately after dining, undoubtedly promotes 
digestion. Nervous persons, and those suffering from dyspepsia, gas- 
tralgia, &c., should not adopt this custom. Those habituated to the 
use of coffee in this manner often suffer serious inconvenience from its 
disuse, the most common one beino: severe and constant congestive 
headaches. A cold infusion of coffee, prepared without cream or sugar, 
is a most wholesome beverage. — C.]^ 

Tea. — The English custom of taking tea, or a simple warm liquid 
meal three or four hours after dinner is a very salutary one, and pro- 
bably disagrees only with those who dine too late, or overload the sto- 
mach at dinner. The purpose of the warm liquid is to assist in the 
separation and absorption of the chyle from the chyme, which takes 
place at this period. And it is obvious that it would interfere with this 
process to introduce solid food into the stomach ; therefore, little or 
nothing should be eaten — certainly not quantities of buttered toast, 
rich cake, and the like. Two or three moderate cups of black tea with 
a little milk and sugar, forms as a w^ash to the stomach to carry away 
the taste and smell of dinner, and remove all acrid materials, left by 
digestion, which might disturb that rest for which the hour now ap- 
proaches. 

644. The practice of dining early, at from one to three p. m., which 
is pursued by the majority of persons in the lower and middle ranks of 
society, would deserve more general adoption on the score of health, 
were it not generally impossible then to devote the time to it, and to 
rest after it, that the principal meal requires. A hurried early dinner, 
if enough to satisfy the appetite, is pretty sure to cause indigestion, 
and disqualifies for exertion afterwards. If, on the other hand, it be 
purposely made light, it may not suffice for the wants of the system, 
and an evening meal or supper will be necessary. The chief objection 
to suppers is that they are indulged in either so freely or at so late an 
hour, that their primary digestion is not accomplished by bedtime. 
Hence flatus and other symptoms of indigestion occur on lying down, 
and may prevent or disturb sleep, and the individual rises on the fol- 

^ [In moderate quantities, varying -with different individual susceptibilities, coffee is 
an energetic and special nervous stimulant, and frequentl}^ produces insomnia. In larger 
doses it is slightly narcotic. Its action is general, it determines no local heat and stimu- 
lation in the epigastrium, but the circulation is accelerated, the anirnal heat augmented, 
the secretions and excretions increased, and the Avhole organism gently excited and revivi- 
fied. Its power of developing animal heat, renders it the proper stimulant to be taken by 
those who are much exposed to the vicissitudes of climate. It is eminently nourishing. 
In an interesting communication made hy M. Gasparin, to the French Academy of Sci- 
ences (March, 1800), some very curious statements were made respecting the part coffee 
plays as a nutritive agent. Starting with the generally admitted fact, that the quantity 
of nitrogenized matter contained in the daily food necessary for the sustenance of a 
healthy adult male may be estimated at from 20 to 26 grammes ; and having noticed 
tliat the miners in the neighborhood of Charleroi were well nourished, strong, and of 
great muscular development, and under a quotidian regimen Avhich contained but 14.82 
grammes of nitrogenized matter, and which was inferior to that permitted in the strictest 
conventional societies, that of La Trappe, for example, he was led to the conclusion that 
their most thriving condition under this amount of food was due to the free use of coffee, 
in which they indulged. As the positive amount of nutritive material it contains is but 
small, l-30th, was this effected by increasing the powers of assimilation, or by retarding 
the destructive processes of the economy, thus rendering the amount of necessary repara- 
tive aliment less? This is still an open question. — C] 



CLOTHING. 429 

lowing morning with a pasty mouth and unrefreshecl. To avoid these 
consequences, the supper shouhl be taken at least two hours before go- 
ing to bed ; and should consist of such light nourishment as is easy of 
digestion, not too bulky, and not disposed to generate flatus. Those 
W'ho use much exercise may take with advantage a little light meat, 
chicken, game, white fish, or lightly dressed eggs, with a small quantity 
of wine and water, or sound beer (if this do not disagree). Those who 
require less sustaining food, as sedentary, plethoric, or inflammatory 
individuals, will find a more suitable supper in a light farinaceous pud- 
ding, bread and milk, or oatmeal porridge ; the last being especially 
useful in persons of costive habit. A few currants, raisins, or a little 
apple with farinaceous puddings counteract their constipating tendency. 
A habit of regularity in the hours of meals is of great importance in 
the preservation of health. The stomach acquires the habit of expect- 
ing and the power of digesting food at regular intervals, and various 
disturbances in its function and in the system result from irregularity. 
Eor this reason it is much better for those w^ho cannot always dine 
early, to keep regularly to the late hour. The evil efi'ects of long 
fasting are partly dependent on the infraction of this rule ; but some 
result from inanition, which has been noticed under the head of causes 
of disease (§ 63). Few delicate persons can bear much exertion of 
body or mind before breakfast ; the practice of an early morning walk 
is only suited to the robust, who feed largely and late on the preceding 
day. When it is borne in mind that food is intended not only to sup- 
ply the slower process of nutrition and reparation of the body, but also 
to afford materials for the immediate protection of the blood against 
the chemical action of the oxygen absorbed in respiration, and of the 
stomach against the chemical action of the gastric juice — the injurious 
tendency of long fasts will become apparent, and the more so in pro- 
portion as the small capacity of the digestive powers limits the quan- 
tity of aliment taken at a time. 



CLOTHING. 

645. The acknowledged purpose of clothing, as means of preserving 
the health, is to maintain as much as possible such an equal warmth of 
the surface and extremities of the body, as may conduce to the comfort 
of the feelings, and promote a free circulation, with sufiicient perspira- 
tion and innervation in all the external parts of the body. But the 
healthful operation of clothing is not confined to its property of retain- 
ing warmth. It is useful also in protecting the body against the inju- 
rious influence of external heat, dryness, moisture, and electricity ; and 
varied modifications of the clothing will best answer these several ends 
under diff'erent circumstances. 

The lower animals exhibit many interesting facts showing instinctive 
or natural provisions for changes in their clothing to suit variations in 
season and weather, from some of which we may derive useful instruc- 
tion. The change of coat in horses takes place in spring and autumn, 
and depends much on the character of the season ; the thick winter 



430 HYGIEXICS. 

coat being slow to come off in a cold spring, but soon changing in con- 
tinued warm weather ; so likewise cold weather in the autumn accele- 
rates the thickening of this coat, which in horses left to nature we find 
abundantly provided before the severity of the weather is established. 
Sheep change their wool only once in the year ; but its rapid increase 
before the winter sets in, and its tardiness in loosening; and fallino- off 
until June, when all the cold winds of the spring have passed by, afford 
useful suggestions as to the propriety of anticipating the cold by the 
protection of dress, and of patiently awaiting its subsidence before we 
remove that protection. Birds moult their feathers early in the 
autumn ; at which period the new plumage thickens in down and 
feathery expansion as the winter sets in. In the spring, many of the 
downy feathers drop off, and are by many tribes appropriated to the 
lining of their nests ; and through the summer the feathers continue 
to get thinner until the moulting season, when all give place to the 
new plumage. 

But attentive observation of the phenomena and habits of animals 
displays to us farther means by which the same coat or plumage varies 
in its protective power with changes of the weather as well as of season. 

Thus cold causes a partial erection (§ 120) of hairs and feathers, 
which has the effect of increasing the thickness of the covering which 
they form, and this retaining in its interstices a layer of warm air, in- 
creases its non-conducting and protective power. On the other hand 
warmth occasions hairs and plumage to lie close and smooth, so that 
they form a covering which is thinner, and more readily permits the 
escape of heat. Horses which are exposed in the winter often roll in 
dirt and mud, which concreting in their winter coat gives to it a thick- 
ness and power to resist heat, which it would be unwise to remove by 
the process of grooming. Hence curried horses require artificial cloth- 
ing. The feathered tribes are generally protected from wet by their 
imbricated plumage, which is rendered more effective by the drooping 
direction which they give to their tails and feathers when exposed to 
rain. But they are supplied with another means of rendering their 
covering water-proof, in the oil with which their feathers are imbued. 
In aquatic birds this is so abundantly afforded from the skin itself, that 
their plumage scarcely ever becomes wet. In other birds there is less 
fat in the integuments ; but the defect is supplied by the instinctive 
habit of pluming and oiling their feathers, wdth frequent inunctions, 
derived from the large oil gland over the tail. It is curious to observe 
how domestic poultry spend the greater part of a wet day in this occu- 
pation, which is no doubt luxurious as well as useful. Another habit 
which may be contrasted with the preceding, is noticed in warm dry 
weather ; that of throwing dust or ashes into the plumage ; perhaps 
the object is to remove any superfluity of oil, or it may be only to 
relieve themselves from the irritation of vermin with which they are 
always infested. Some land birds, more rationally, delight in washing 
under the same circumstances. 

The preceding facts are not devoid of instruction in regard to the 
dress of human beings, who should learn to cover their nakedness 
under the guidance of experience and reason, which may be better or 



CLOTHING. 431 

worse than instinct, according to whether they are well or ill exercised. 
It argues little for the boasted superiority of man's reason, if it do not 
guide him to means more effectual in resisting the hurtful action of 
external temperature than those instinctively possessed by the lower 
animals ; and yet there can be li.ttle doubt that none of these suffer 
from cold, wet, and atmospheric changes, to the degree in which human 
beings do. In truth, reason and common sense are too frequently set 
aside by foolish habits originating in vanity, fashion, caprice, prejudice, 
indolence, ignorance, or some such evil influence, and disease and in- 
firmity are the penalties incurred by folly. 

It will be the most convenient and concise mode of practically 
improving the subject of clothing, by considering the modes in which 
the physical influences which injuriously affect the body may be best 
intercepted by articles of dress. 

646. We guard against external cold^ by covering the body with 
such materials as, by their low conducting power and thickness, pre- 
vent the undue escape of animal heat. The most effectual for this 
purpose are furs and woollen fabrics ; next rank thick spongy silk and 
cotton stuffs ; and the lowest in power are linen cloth, and silk and 
cotton webs, so thin as to lose their protective property. The porosity 
of furs and woollen garments is valuable in permitting the escape of 
insensible perspiration, and on account of its lightness ; but it impairs 
their protective quality against strong currents of cold air, especially 
if this be either very dry or very damp. Cold air in strong motion 
penetrates woollen stuffs of considerable thickness, and carries with it 
a dry or damp chill according to its hygrometric condition. In this 
power of penetration it is probably aided by the law of diffusion of 
gases (which applies to different amounts of watery vapor in air (§ 72). 
This consideration will account for the peculiarly chilling operation of 
a desiccating east wind and a cold fog ; and the interference of both 
with the cutaneous perspiration as well as circulation, explains much of 
their injurious influence. The best protection against these agents, is 
to be found in leather or even more impervious textures, such as India- 
rubber cloth or oil-cloth ; but these should not be worn too near the 
skin, lest they should prevent the proper escape of its perspiration, 
and cause an unhealthy dampness of the surface. Chamois leather 
may be used as a waistcoat over one made of flannel ; and the still less 
pervious textures may be employed either in detached pieces, as in the 
piline and India-rubber chest protectors, or loin-belts, or in way of an 
outer garment as in Mackintosh capes, cloaks, and overalls, and these 
should be provided with ventilating apertures under the arms and else- 
where, to permit the free escape of the cutaneous exhalations. In this 
way we somewhat imitate the covering of birds, which in their flight are 
very much exposed to cold winds, damp or dry ; their plumage being 
porous and downy underneath, but denser and impervious externally, 
whilst by the overlapping of their feathers a free escape is left for the 
exhalation from the skin. A similar advantage is obtained in an in- 
ferior degree by using several garments of different degrees of permea- 
bility, the warmest and most porous being worn next the skin, and 
others externally ; this alternation of successive layers of different 



HYGIEXICS. 



properties increases the non-conducting power of clothing, and reduces 
the penetrative influence of cold and damp. There are very few in- 
stances in which flannel or fleecy hosiery may not form the best under 
dress during at least eight months in the year in this country, and a 
thinner material of the same kind, or merino (a mixture of wool and cot- 
ton), during the remaining four. The exceptions are persons of very 
irritable or relaxed skin, for whom an elastic cotton or spun silk mate- 
rial may be more suited. Warm under-dresses should not be worn in 
bed, as they then are apt to relax the skin too much, and render it more 
susceptible to the impressions of cold during the exposure of the day. 
Calico is the best material for the night dress ; any required additional 
warmth being afforded by the bedclothes. It is of great importance 
to maintain the warmth of the extremities ; there are few w^ho can safely 
dispense with warm worsted stockings in the winter months ; and those 
liable to coldness of the feet should also wear flannel or merino drawers 
and flannel linings to their shoes and boots. 

647. Some of the kinds of clothing best suited to protect the body 
from ivet and damp, have already been mentioned in the water-proof 
materials which also prevent the penetration of cold winds. For the 
exclusion of wet they should be worn outside of all other clothes, for 
the sake not only of permitting a freer escape of perspiration, but also 
of preventing the penetration of moisture into any part of the dress, 
for although the wet may not reach the body, its proximity may chill 
by evaporation. For the same reason the cardinal rule of keeping 
the feet dry is better accomplished by outer coloshes, gutta-percha 
soles, and varnish, or other means which exclude the wet on the outer 
surface of the shoes, than by inside cork soles or oil-silk socks, which 
allow the leather to be soaked in wet, and only intercepts its contact 
with the foot. 

648. The change from winter to summer clothing should be made 
gradually and with great caution ; and it is better to be tardy than 
hasty in change. The fitting period will vary in different seasons, but 
it rarely occurs before the month of May, often not until June ; for 
although there may be warm weather earlier, it is generally of brief 
duration, and is alternated with bleak winds, which render the spring 
months peculiarly trying, and often cause more illness than all the con- 
tinued severity of the winter. Much of this is to be attributed to the 
too early change of dress (§ 645). The converse rule may be applied 
to the change at the end of the summer ; which is most prudently 
made in anticipation of the permanent cold. Many of the autumnal 
diseases arise from the great variations of temperature between day 
and night, and from sudden changes of wind, and these take more 
elTcct by finding the body relaxed by previous heat (§§ 25, 81), and 
yet protected by only summer clothing. 

649. In this country even in summer the clothing is required to main- 
tain sufficient warmth, more than to exclude heat ; but it is now reduced 
to the thinnest and lightest materials, a slight woollen or cotton fabric 
being commonly retained next the skin to prevent the chilling damp- 
ness of the linen when wet with perspiration. Frequent changes of 
linen, where practicable, might supersede this precaution, and with free 



CLOTHING. 433 

ablutions are wholesome and refresliinoj durino; Intense heat. Protec- 
tion against solar heat and hot air is best afforded by loose linen vest- 
ments of light color, large straw hats, bonnets, veils, &;c., which it is 
unnecessary to particularize. 

650. It is very probable, that atmospheric electricity may exert an 
influence on the health, which may be, in some degree, counteracted by 
modifications of the dress. Thus silk vestments have a considerable 
protective influence by their property of non-conduction ; and if worn 
next the skin, by friction they excite electricity, which is supposed by 
some practitioners to operate as a hygienic agent, in persons disposed 
to rheumatic and nervous diseases. Farther observations, carefully 
conducted, are needed to determine these points. 

651. Under particular circumstances or conditions of the system, 
additional warm clothing is necessary; such as — in infancy, when the 
calorific power is low ; in old age ; in convalescence from acute dis- 
eases ; during fatigue and other states of weakness ; and in organic 
diseases of the heart, when the circulation is feeble ; in case of priva- 
tion of food ; during the operation of purgative or diaphoretic medi- 
cines ; and when circumstances prevent the use of a proper amount of 
exercise. Under the influence of these conditions, the feeling of chilli- 
ness, particularly on the surface and in the extremities, is an indication 
of the need of more clothing, and if this be used to prevent the sensa- 
tions of cold it will often counteract those disturbances of the circula- 
tion and internal congestions to which the weakened body is liable 
{§§ 79, 292), and vvdiich lay the foundation of many diseases. 

No part of the frame requires the protection of clothing so little as 
the head and face. The final cause of this comparative freedom from 
the bondage of garments, is obvious in a part where free communica- 
tion with the exterior is necessary for the senses, breath, speech, and 
nourishment. The physiological cause of the greater power of the head 
in resisting cold, may be probably found in the larger size ttnd less 
varying caliber of its bloodvessels (§ 9SQ), which, even in weakened 
states of the circulation, secure an amount of blood which may cause 
a sense of heat and fulness, when other parts are suffering from the 
opposite feeling (§§ 330, 331). But even for the head, during expo- 
sure to the air and during the night, it is expedient to use such light 
covering as may prevent checking the perspiration of the surface, and 
more particularly the ceruminous secretion in the ears, the proper con- 
tinuance of which is essential for the preservation of hearing.- I do 
not, therefore, approve of a favorite modern practice of altogether dis- 
carding nightcaps, and I have known it to induce catarrhal affections of 
the eyes and nose, earache, and deafness. Those who thus suffer, or 
from dryness of the scalp, may find much benefit from wearing at night 
an oil-silk cap over a thin nightcap. 

Various other cautions and directions with regard to clothing are 
sufiiciently dictated by principles of common sense to supersede the 
need of our dwelling on them — such as the frequent changing of gar- 
ments, especially under ones, for cleanliness sake ; the avoidance of all 
tight ligatures, lacings, or buttonings, which may cause improper pres- 
sure on any part of the body, and interfere with free motion, circula- 
28 



434 



HYGIENICS. 



tion, perspiration, &c. The invention of India-rubber web and other 
eh^stic materials, has supplied a valuable means (not used so generally 
as it deserves) of avoiding these evils, and of yet maintaining a due 
apposition and attachment of various articles of dress. 



AIR AND TEMPERATURE. 



652. The subject of impure air as a cause of disease, has already 
occupied our attention (§§ 72, 73). We now have to notice the states 
of the air most conducive to health ; and inasmuch as temperature is 
chiefly conveyed through the air surrounding the body, it will be con- 
venient to include a few remarks on this topic under the same head. 

The invigorating influence of pure, fresh air may be partly referred 
to its superior purity more perfectly adapting it to the purpose of re- 
spiration, but somewhat of its refreshing effect is due to its direct 
operation on the nerves and capillaries of the surface of the body, and 
through them on the functions generally. This is exemplified in the 
reviving eifect of a current of fresh air, or of fanning, on persons in a 
state of faintness, and this effect is more remarkable when the air is 
cool and the body has been previously weakened by heat and confine- 
ment ; but the continued action of a cold current would be hazardous 
under these circumstances. The less marked but more enduring bene- 
fits of fresh air, are experienced in rides, drives, or other exercises, 
passive or active, which are universally acknowledged to be essential 
means of maintaining the bodily health. To obtain the greatest amount 
of good from these airings, it is useful not only to resort to localities 
where the air is most pure and free from contamination, but also to 
vary its qualities in other respects. Thus the inhabitants of valleys 
derive benefit from the air of hills ; those of inland places from that 
of the sea ; and residents on the sea-coast derive advantage from drives 
inland. For a similar reason, much improvement of health often 
results from continued travelling by land or sea, and although this 
comprises other hygienic elements besides change of air, experienced 
travellers rarely fail to distinguish this as one of sensible efficacy, 
exercising a marked effect on the several functions. Similar bene- 
ficial results sometimes ensue from moderate and favorable changes of 
weather, which bring an altered state of atmosphere even to our own 
homes. It is by no means certain on what physical properties depend 
the all-varying hygienic influences of air in changing weather and dif- 
ferent localities ; but it may be useful to notice somewhat of the ope- 
ration on the body of air in different states of dryness and moisture, 
temperature and purity. 

653. A very dry air exerts on the body the physical influence of 
rapid evaporation and a high degree of electric tension ; the resulting 
operation on the functions is generally more or less stimulating. The 
tonicity of the textures is usually augmented, whilst the desiccating, 
and probably also the electric action of the air on the cutaneous and 
mucous surfaces, induces an excitement which is beneficial in those of 
relaxed and leucophlegmatic habit ; but in the irritable and sanguine, 



AIR AND TEMPERATURE — DRY AIR. 435 

may lead to inflammation or fever. A very dry air, the effect of which 
is increased by its heat or motion, impairs the perspiring power of the 
skin, and excites various kinds of cutaneous inflammation, often w-ith 
fever and thirst. In moderate degrees, and at mild temperatures, dry- 
ness of the air is salutary, by facilitating the purification of the blood 
in the lungs (§ 72), by improving the tone of the moving fibre, by 
checking tendencies to excessive secretion, and by counteracting various 
septic processes, both within and without the body, which are generally 
promoted by humidity. We formerly had occasion to notice that dry-, 
ness of the air is one of the best safeguards against the activity of 
miasmatic poisons (§ 83). Another reason for commonly preferring a 
dry air as the most healthy, is because we can more efliciently coun- 
teract the injurious operation of dryness than that of moisture. A 
judicious use of bathing, v/arm or cold, exercise and friction, which by 
inducing gentle sensible perspiration remove the dryness of the skin ; 
the prevention of too rapid an evaporation from the surface by means 
of inunction, emollient applications, and difficultly pervious coverings, 
such as oil silk, leather, &c., on parts which suffer, will generally suc- 
ceed in preventing the hurtful influences of dryness in the air without 
interfering with its salutary effects. 

Dryness of the air is most permanently obtained in connection with 
a dry soil, from which the water of rain and dew speedily drains off, 
or evaporates, as on rocky surfaces ; or sinks deeply, as in sand, chalk, 
and light gravel. The nature of the subsoil is therefore of the greatest 
importance in determining the character of the air of a locality; and the 
kinds above mentioned are the most favorable to permanent dryness of 
the air. A declivity or undulating surface and a freedom from dense 
foliage and very luxuriant vegetation, contribute also to the dryness of 
a neighborhood, and generally thereby to its salubrity. Dryness in 
the air is also remarkably connected with the prevalence of certain 
winds in this hemisphere, especially those from the east, the aridity of 
which is due not only to the much rarer occurrence of rain w'hich they 
bring with them, but also to their smaller proportion of dissolved 
moisture. And because such wdnds prevail more in strength and fre- 
quency on the eastern than on the western portions of these countries, 
the former have for the most part a drier air than the latter. But in ad- 
dition to dryness, easterly winds have other qualities which detract much 
from their salutary influence on the animal frame, and often prove 
positively injurious. Thus the north-east and due east winds are 
remarkable for their bleakness and penetrative coldness (§ 646) ; and 
except in persons whose circulation is naturally strong and kept in 
activity by exercise, their tendency is to check the passage of the 
blood in the surface and in mucous membranes, and impair the func- 
tions connected therewith. Farther, the objection to exposed situations 
on account of the capricious and changeable character of the winds 
which act on them, applies with peculiar force to those with an eastern 
aspect, on which the transition is more than usually sudden and 
extreme, from the power and bleakness of the returning cold. 

The south-east wind is also dry, and in winter and spring differs 
from those more from the north in its milder temperature ; but as sum- 



436 



HYGIEXICS. 



mer advances, it is remarkable for its sultry and oppressive quality, 
which in south Europe is exemplified in its acme in the operation of the 
sirocco. Much of the overpowering influence of this air may be ex- 
plained by its desiccating operation (manifest not only in animals by 
the thirst and feverish dryness of the skin and mouth, but also in plants 
and trees by the -drooping of their leaves), combined with the relaxing 
agency of heat on the vascular fibre, by which the powers of the circu- 
lation are enfeebled, and the purifying processes of respiration and se- 
cretion are more or less impaired. But doubtless something of the 
peculiar effects of a south-east wind is due to electric tension ; and in 
this countr}^ their extreme manifestation generally precedes the occur- 
rence of a thunderstorm ; nor should be forgotten the fact formerly 
mentioned (§ 92, note)^ that during the prevalence of this wind espe- 
cially the air becomes surcharged with animalcule tribes, and certain 
epidemic diseases, especially Asiatic cholera and sometimes influenza, 
make their greatest progress. 

654. A damp or moist air, irrespectively of its temperature, may be 
considered as lower than dry air in its vivifying power, inasmuch as it 
contains less free oxygen, and has a lower diff"usive property to aid in 
its pervading the lungs in respiration. The greater facility which it 
aff'ords to processes of decomposition and infection should also be scored 
against its salubrity, as well as other points in which it may be con- 
trasted with moderately dry air. A warm moist air is universally 
relaxing (§§ 25, 123), and unless in persons of dry skin and over-braced 
vessels, is oppressive and debilitating. Under its influence, perspira- 
tion accumulates on the surface, perpetuating its relaxation if warmth 
continues, and chilling it and impairing its circulation and excretion if 
cold ensues; and the very evaporation from the moistened surface, 
which even in mild damp air may occur from draughts or currents, may 
under such circumstances cause an injurious chill. More surely perni- 
cious in this manner is cold damp air, which is proverbially unhealthy, 
and its disordering action may be in great measure traced to the phy- 
sical properties of abstracting heat and electricity, and of checking 
perspiration and assimilation, which it obviously possesses. Hence 
ensue the retention of lactic acid in the blood, the formation of oxalic 
instead of lithic acid, and the imperfect elaboration of the plasma ; and 
these aberrations from the normal chemistry of the body, may manifest 
themselves in the shape of various diseases of the blood and circulation, 
of which rheumatism, neuralgia, sundry cutaneous affections, cachectic 
ulcers, tubercles, scrofula, &c., are familiar examples. 

The most efficient cause of dampness in the air is the permanent re- 
tention of moisture on or near the surface of the ground, as in low 
grounds in which clay prevails, and where water accumulates or is im- 
perfectly drained off, and where evaporation is retarded by the shade 
of many trees, or of high rocks or hills. But independently of soil, a 
house may be damp from its own materials, which from recent con- 
struction, or from their tendency to attract and precipitate humidity 
(as in case of those built of limestone or marble), are constantly im- 
pregnating the contained air with humidity. Wet weather and damp 
winds, such as the south-west, are less injurious causes of humidity, 






AIR AXD TEMPERATURE — MOIST AIR. 437 

because less permanent ; but their influence is often manifest during 
their continuance, and always most so in localities that are damp from 
other causes. The air of the seaside, even on the south-west coast, al- 
though generally abounding in humidity, is far less injurious than that 
of damp places inland ; apparently because much of the sedative and 
chilling operation of marine humidity is counteracted by the stimu- 
lating influence of the saline particles which it contains. The diff"erent 
effect of a sea fog and a land mist is well known. 

The hygienic directions with regard to moist air are chiefly of a pro- 
tective or counteracting character. Artificial heat is the most availa- 
ble and efiicacious desiccating agent which we can command; and, if 
combined with adequate ventilation, it may do much to remove damp- 
ness of air within doors, whether arising from the soil or from the build- 
ing. In warm weather, when fires are unpleasant, much unhealthy 
moisture may be removed from the air, by so adjusting doors and win- 
dows, or air-holes, that ventilation may be secured without opening 
those facing the dampest vicinity. In limestone districts, much good 
results from keeping large pans of quicklime in several apartments, 
especially those of the basement and ground-floor. This expedient, for 
reasons before mentioned, is a serviceable precaution against malarious 
and infectious diseases; its utility has long been known in preventing 
meat from becoming soon tainted in a damp larder. 

To diminish the dampness of clay and marshy soils in the immediate 
vicinity of dwellings, much may often be done by an efficient system of 
covered drainage ; by the removal of superfluous trees and shrubs ; and, 
where practicable, by covering the surfaces which are most constantly 
wet, with light sand, gravel, brick and mortar rubbish, or some similar 
light and porous material, which may form an artificial superstratum 
and intercept the influence of the damp ground. The insalubrity of 
many low parts of the metropolis, especially in Pimlico and Westmin- 
ster, has been wonderfully diminished by the latter expedients. A 
parallel protection against the damp of limestone w^alls of houses is 
obtained by the process of battening or covering the wall with wood 
and canvas, or lath and plaster. The free use of concrete, or. of slate 
or metallic plates in the foundations of houses, to prevent the rising in 
the walls of moisture by capillary attraction, should never be neglected, 
particularly in damp localities, where the lower parts of the building 
are likely to be inhabited. 

6d5. The subject of temperature of the air has been frequently in- 
troduced in the preceding remarks, and it will be superfluous to dwell 
long on it here. The average temperature most generally conducive 
to comfort and health, is about thirty-five degrees (of Fahrenheit) be- 
low the heat of the interior body; that is, 63^; blood-heat being 98°. 
In sustaining an artificial temperature in the air, it is rarely expedient 
to exceed this; for the purity and invigorating properties suffer at 
higher temperatures, and if more warmth is needed than what results 
from air at this point, it should be supplied by clothing or other means. 
The advantage of keeping the atmosphere of apartments considerably 
cooler than the body itself, consists, not only in. the greater amount 
of oxygen contained in a given bulk, but also in the greater force with 



438 



HYGIEXICS. 



Tt'hich the foul air of respiration is carried away from the breathing 
passages, and a pure air supplied, in consequence of the difference of 
temperature maintaining a current. The converse of this is a chief 
reason why over-heated rooms are peculiarly oppressive, unless the air 
he changed by efficient ventilation, and why warming rooms by stoves, 
or heated air, causes a feeling of closeness which does not result from 
open fireplaces, which communicate heat chiefly by radiation, and 
leave the air comparatively cool. The animal body being naturally much 
warmer than the surrounding air, operates as a ventilator for itself, by 
the same consummate adaptation of pneumatic laws as that which supplies 
a flame or fire with a continued current of fresh air; and as we see a 
fire burn brighter and clearer in frosty weather, so an animal breathes a 
purer, denser air, which, if not injurious by its cold, is refreshing and 
invigorating to the body. Not only healthy and robust persons, but 
also som^e who are asthmatic, or otherwise weak in respiratory power, 
acquire increased strength and energy in clear cold weather: and even 
those who, from weakness of circulation, cannot resist continued cold, 
and usually require a mild atmosphere, are generally refreshed and 
benefited by breathing cold air for short periods, when exercise and 
warm clothing protect them against its sedative and chilling effects. 

6dQ. The use of artificial heat is greatest in young infants and very 
aged persons; in whom the intrinsic calorific power is too low to bear 
safel}^ even the temporary exposure to wintry air just mentioned as 
useful to some weakly subjects. So, too, those who sufi'er in the lungs 
and air-passages from even brief impressions of cold, which is the case 
with the greater number of pulmonary invalids, should not venture into 
the open air during cold weather, without the protection of a respira- 
tor, which acts as a kind of clothing to the air-passages; and although it 
detracts from the refreshing coolness of the open air, it does not mate- 
rially impair its purity. I have known this instrument prove useful 
also' in the case of anaemic subjects, and others of low calorific power, 
not merely by protecting the air-passages, but also by retaining the 
heat which is generally expended in the expired air.^ 

657. The necessity of maintaining the purity of the air by its con- 
tinued change has repeatedly been noticed in the present and preced- 
ing chapters (§ 72). In cold weather, this change is greatly promoted 
by the difference of temperature in the air heated by respiration or by 
the fire of a room, and that of the surrounding atmosphere, and the 
increased ventilation thus insured has been mentioned as a cause of the 
more invigorating properties of the air in winter. In hot weather, on 



1 Various expedients for retaining the warmth of the breast for the purposes of animal 
temperature, -were long since recommended by Dr. Arnott and others. An incident in 
point, "which occurred to myself many years since, may afford a useful hint to others in a 
similar predicament. I had to go a long journey on a cold winter's night; and there be- 
ing no room inside the mail, I was obliged to ride on the outside, although insufficiently 
clothed for the exposure. Reflecting on the great loss of heat manifest in the steaming 
breath of myself and fellow-passengers, I endeavored to retain a portion of it by entirely 
covering the head and face witli a silk pocket-handkerchief, the lower ends of which were 
closely tucked inside the buttoned coat. The result was a retention of warmth, not in 
the face and chest only, but even in the extremities, more comfortable and diffused than 
an additional greatcoat could have produced. 



TEMPERATURE AXD AIR — VENTILATIOX. 439 

the Other hand, and in apartments heated through the air more than by 
radiation, it is necessary to provide means to assist the motion of the 
air. In summer, this may usually be effected by open windows and 
doors; and the close smell which shut-up rooms acquire in summer, 
generally suggests this remedy. In India, and other hot climates, 
where even the outer air is so hot and still that it supplies no movement, 
machines are used for creating a current of air, and of farther cooling 
it by evaporation from a moist surface. Even sprinkling floors and 
walls with water is useful, not only in cooling the air, but also in thereby 
promoting its motion. 

In cold weather, some degree of ventilation is commonly insured by 
the fires employed for the purpose of warmth ; but it is often in an 
irregular or insufficient manner ; as by draughts of air under doors, 
and throuo-h the chinks of floors, which cause a cold current on the 
feet and lower parts of the body, whilst the head and breathing pas- 
sages, which are above the level of the fireplaces, are above the current, 
in a stratum of vrarm and less pure air. It is quite true that by the 
law of difl"usion of gases, as well as by the force of the currents, and 
other means of agitating the air, a change is effected in the whole air 
of a room ; but it is so, less completely and rapidly than is desirable 
for so important a purpose as the constant supply of pure air for respi- ' 
ration. To obviate these defects, various ventilating contrivances have 
been recommended, and none for simplicity and efficacy excel those 
recommended by Dr. Arnott, which not only form apertures calculated 
to promote a continued change of air in the room, but, by means of a 
simple self-adjusting valve, they may be made to prevent too strong a 
current or one in a wrong direction. For perfect ventilation, two aper- 
tures (or sets of them) are requisite ; one for the supply of fresh air, 
another for the exit of that which is foul. These should be placed at 
opposite sides of the room, and it is generally advised that the outlet 
should be placed near the ceiling, which is certainly the best position ; 
and it may be made into the chimney where a fire is used (an efficient 
valve preventing the influx of smoke), or through the ceiling or roof, 
or in a top window-pane, where there is no chimney. For the purpose 
of affording the freest influx of air, an aperture near or in the floor 
would be the most suitable position; but it is objectionable on account 
of the chill which it communicates to the feet and lower parts of the 
body. Commonly, therefore, the inlet for fresh air may be made in 
the upper pane of a window or panel of a door, most remote from the 
outletting aperture ; and to prevent draughts, and to promote the dif- 
fusion of the air through the room, the opening should be covered with 
wire-gauze, or finely perforated zinc plate, in addition to which, if 
necessary, an oblique screen of wood or curtain may be placed before 
it to direct the current to the walls and ceiling. By these means, the 
fresh air, which is heavier, because cooler than the air of the room, 
gradually falls, and is dispersed, displacing the warmer foul air ; and 
reaches the middle of the room cool and refreshing for the heads and 
breaths of the inmates, yet causing no draughts on the lower extremi- 
ties. In very cold weather, it is certainly advantageous to have the 
supply of external air moderately warmed before it enters the room ; 



440 HYGIENICS. 

and the best method of effecting this, is by means of a well-regulated 
warm-air stove, or an Arnott stove, with a current of fresh air directed 
on it, placed in the hall or at the bottom of the staircase. This inlet 
of a gently warmed air, is useful, not only by taking the excessive chill 
from the outer air, but also by affording such an influx into the house 
as supersedes those irregular draughts, which, for want of 6>ther supply, 
force their way through every chink, hole, and cranny in the floors or 
walls, and which, besides a chill, often bring with them dust and bad 
effluvia acquired in their passage from without (§§ 72, 73). The ex- 
treme dryness of the air thus warmed may be removed by shallow 
earthen pans containing water, placed on the stove. 

658. The ventilating force operating in all the cases hitherto no- 
ticed, is that depending on atmospheric pressure, displacing air rendered 
lighter by heat, animal or artificial; and this force, properly applied 
and directed, will suffice for the ventilation of ordinary dwellings. But 
for large public buildings in which great numbers are congregated, or 
W'here other causes of contamination or impurity operate, as in manufac- 
tories, hospitals, mines, holds of large ships, &c., this force maybe ineffec- 
tual ; and even when aided by extra fires and lengths of chimney, it is 
not sufficiently under command or regulation to be properly adequate 
for the purpose. The other forces which have been applied to effect 
ventilation on a large scale, are mechanical powers, and the operation 
of a jet of high-pressure steam. The latter is very efficient in creating 
a strong current of air which is chiefly applicable to the drawing off of 
•foul air. It is proposed to be applied by Mr. Barry, as a chief force 
in the ventilation of the new Houses of Parliament; but time will show 
how far it will prove adequate. The noise caused by it would be an 
objection in some cases. Mechanical ventilation has long been prac- 
tised through the revolving fan-wheel ; but Dr. Arnott has shown that its 
propelling power is very limited ; for where resisted by any opposing 
current equal to the pressure of a column of seven inches of water, 
it no longer creates a current, but revolves with increased rapidity, 
carrying the air with it instead of through it. This scientific physician 
has devised a mechanical ventilating apparatus, which in amount and 
steadiness of power, and the perfect facility with which the air supplied 
can be regulated, excels every contrivance hitherto accomplished or 
proposed. Such a machine, which is a kind of pump, moved by steam, 
and which propels air in a precisely measured quantity and regulated 
temperature, has been constructed under Dr. Arnott's directions at the 
Hospital for Consumption at Brompton ; and so far as can be judged 
from a trial of four or five months, appears to be perfectly successful 
in its operation. This machine introduces into the building about two 
thousand cubic feet of air per minute, which passing over six hundred 
square feet of surface heated by steam, supplies an abundant amount 
of fresh air, moderately warmed. The foul air escapes through valvular 
apertures into the chimneys of each room. 

659. Besides the supply of fresh air to the interior of buildings, 
means to preserve from contaminating effluvia are frequently required, 
especially in large towns. Systematic and scrupulous cleanliness, and 
an adequate and air-tight drainage are most effectual for this purpose. 



BODILY EXERCISE. 441 

Some recommendations on these subjects have been already given 
under the head of exciting causes of disease (§§ TO, 73). For the 
purpose of cleansing, an abundant supply of water is essential to the 
wholesomeness of a habitation ; the evils of impure air are commonly 
experienced where this purifying element is scanty. Additional means 
of purification are afforded by certain chemical agents which absorb or 
decompose noxious effluvia. Lime is a cheap and useful material for 
this purpose, and may often be advantageously used both by lime- 
washing walls and ceilings, and by pans of quicklime kept in the base- 
ment story of houses near any source of foul air. Other disinfecting 
agents are still more powerful, and at the head of them undoubtedly 
stands chlorine, which is invaluable in destroying noxious effluvia, the 
source of which cannot be stopped. Chloride of lime and dissolved 
chlorinated soda, are convenient materials to afford a moderate supply 
of the gas, which,- if required, may be extricated in greater quantity 
by the addition of an acid. But a cheaper and more abundant source 
is supplied by black oxide of manganese, common salt, and sulphuric 
acid; the acid being added from time to time in small quantities 
throughout the day.^ Under circumstances in which the operation of 
chlorine is too irritating, nitric or acetic vapor may be substituted, 
but they are less effectual and must be used in greater abundance. 
In houses in which unmanageable drains or immovable cesspools taint 
the air, some of these disinfecting agents should be kept in perpetual 
operation.^ 

BODILY EXERCISE. 

660. The want of exercise has been noticed as predisposing to, and 
exciting disease (§§ 24, 65) ; and the opposite extreme, excessive exer- 
tion, was mentioned as equally detrimental in its effect on functions 
and structures (§ 64). The place which exercise occupies as a hygienic 
agent is therefore between these extremes ; and its utility and import- 
ance will be proportioned to the regularity and discretion with which 
it is practised. 

Moderate and sustained exercise in healthy air, as in walking, 
riding on horseback, and in various occupations and pastimes, excites 
into activity most of the functions of the body, especially the circula- 
tion, and respiration, or those intimately connected with these, the 
secretions and animal heat ; and provided the fatigue or exhaustion 
resulting from this excitement be adequately removed by sufficient rest 
and sustenance, the functions gradually gain vigor by their activity, 
and the structures exercising them acquire a fuller and healthier deve- 
lopment. The muscles especially, including the heart, manifest an 

1 A cheap and convenient apparatus for fumigating with these materials has been con- 
trlTecl by Mr. Smith, of White Street, Borough, and to be obtained of Hoare & Co., 123 
Newgate Street. 

2 The subject of public sewerage and others connected with these topics, is too extensive 
to be entered on here ; and the reader will find much valuable information in the Report 
lately published by the Sanitary Commissioners, from whose continued labors much good 
may be expected. 



442 



HTGIEXICS, 



increase of strength and firmness ; the bloodvessels are improved in 
tone, by which they distribute and equalize the flow of blood through 
them, and prevent partial congestions and obstructions ; and the blood, 
actively carried through the organs and textures, undergoes the com- 
plete series of changes from nutrition, purification, arterialization, by 
which its integrity is maintained, and it is adapted in its turn to sus- 
tain the several functions of the body. The appetite, the digestive 
powers, the intestinal action, the warmth of the surface and extremi- 
ties, the spirits, and temper, are generally all improved by the habit of 
regular exercise ; and what can we say more to recommend any hygi- 
enic agent? But as much of its beneficial effect depends on the judi- 
cious manner in which exercise is adapted, in kind, time, and degree, 
to the strength, habits, occupation, age, sex, and other circumstances 
of the individual, it may not be superfluous to indicate a few cautions 
and directions on the most important of these points. 

661. In childhood, youth, and early maturity, when the joints are 
supple, the textures in full elasticity, and the whole frame adapted to 
the quickest and most varied movements, diversity and activity in mus- 
cular action are suitable and salutary ; and there is pleasure as well as 
benefit in exceeding common modes of -exercise by varied feats of 
agility and strength, which call into play all the muscles of the body, 
as in running, leaping, climbing, wrestling, rowing, and various athletic 
games, such as crickets, fives, tennis, quoits, kc. But at this youthful 
age there is less power of endurance of continued fatigue than in 
maturer life, and the body more absolutely requires repose after exer- 
tion. The health of young persons, especially of the female sex, is 
often much injured by too long walks, especially if frequently repeated, 
whilst they may comparatively sufl"er little from greater exertion for a 
shorter period, as in dancing, or riding on horseback. In adult age, 
on the other hand, prolonged exertion is better borne than exertions 
requiring great agility of movement ; and unless a youthful mobility 
be preserved by continued practice, more sober and steady motions are 
more fittino: to the sedate a^e. Exercise on foot and on horseback on 
the ordinary mode, except among the working classes, whose occupa- 
tions engage them in various kinds and degrees of muscular exertion ; 
and in all these species of exercise and work, experience teaches, long 
before the period of middle age, that more is safely and comfortably 
to be done by steady and sustained exertions, than by sudden or rapid 
efi'orts. But it does not therefore follow, that the exercise taken for 
the sake of health in middle age should be monotonous or slow. Per- 
sons much engaged in employments either sedentary or confining them 
within doors with little exertion, would feel little benefit or refreshment 
from the hour or two which they can spare for out-of-door exercise if 
it were passed in mere sauntering or strolling on an unvaried road. A 
brisk walk, diversified as much as may be in direction, including, if 
possible, ascents and descents, and away from the vicinity of the smoke 
and efiluvia in which the rest of the day is spent, and alternated with 
an inspiriting ride on a free-paced horse, or with the healthy exercise 
of active gardening, or the like pursuit, will most profitably fill up the 
time which the middle-aged man of business can devote to exercise, 



BODILY EXERCISE. 443 

and he will then soon find it a very safe and remunerating investment. 
On the other hand, he who, forgetting what becomes his age, relishes 
no exercise but those associated with the excitements of the ball-room, 
the cricket-ground, the rowing-match, or the hunting field, speculates 
with a capital of mobility and elasticity which he may not possess, and 
although he may sometimes boast of a successful result in recovering 
activity and health lost through previous habits, yet he encounters a 
perpetual risk of breaking down under the unusual strain to which he 
subjects his frame, and he gains none of that gradually renovating and 
invigorating influence which is produced by more moderate exercise 
regularly practised, although varied from day to day. In old age, the 
sphere of exertion is still farther limited by functional and structural 
changes before noticed (§§ 48, 546), and exercise, although still salu- 
tary, must be still farther restricted in degree and variety. Quiet 
walking or riding on horseback may be practised by many, even far 
advanced in years ; and carriage exercise (such as it is, which is 
scarcely any) remains for the more infirm. The selection of these, 
and the extent to which they are beneficial, will depend much on the 
previous habits as well as on the present condition of the individual. 
If a man has lived a sedentary life, and has become stiff and prema- 
turely old in consequence, this is not the time to commence habits of 
activity, which would endanger the integrity of his vegetating or mine- 
ralized structures (§§ 543-6). A similar caution is applicable to those 
who have lived too fast ^ and by various excesses and undue excitement 
and strains, have exhausted their vital powers and accelerated the de- 
generative changes in their textures ; such persons manifest by their 
feeble and tottering gait and breathlessness on exertion, an inaptitude 
for exercise, which should caution them against its being attempted. 
Carriage airings and gentle frictions of the surface and extremities are 
here the best substitutes. It is different with those, who, by a tempe- 
rate and judicious mode of living, Avith habits of activity proportioned 
to the strength and age, have economized their vigor, and given fair 
play to their constitutional powers ; these may be said to enjoy a green 
old age, in which a capacity for moderate exercise continues to be not 
less a source of recreation and comfort than a means of sustaining 
health ; but even these fine and in all respects venerable specimens of 
ameliorated humanity sometimes need professional warnings against 
presuming too much on their well-husbanded strength. They are often 
carried off by acute attacks, which have been brought on by their step- 
ping out of their sphere of safety, which although wider than usual at 
their age, has nevertheless limits, which the steady hand of time is 
daily narrowing, but in so gradual and imperceptible a manner, as to 
escape the attention of their own mental powers, now also on the wane. 
Hence one act of imprudence may be followed by fatal results ; and 
that may be deemed to be imprudent which in any material degree 
exceeds the bounds of the accustomed habits. 

662. The times at which exercise is most salutary, in relation to 
meals, occupation, and repose, are commonly those in which the bodily 
powers are not too low from fasting, fatigue, or wakefulness, nor op- 
pressed by the process of digestion. Exercise before breakfast is suita- 



444 



HYGIENICS. 



ble only to the robust, and those who have fed late and largely on the 
preceding day ; delicate persons commonly become faint from exercise 
at this time ; and others that do not immediately suffer, lose a degree 
of the appetency and digestive power which render the meal agree- 
able as well as useful, and thus consequently are more languid during 
the early part of the day. Shortly after breakfast is commonly an 
eligible time for exercise ; this meal is sufficient to remove the squeam- 
ishness or faintness apt to arise from an empty stomach, yet it is not, 
or should not be, so heavy as to oppress the bodily powers, or prevent 
their capacity for moderate muscular exertion. Those who can com- 
mand the time, will find it advantageous to intersperse their sedentary 
occupations with short periods of exercise, if possible, in the open air ; 
if this be only for ten or fifteen minutes, once or twice in the course of 
the forenoon and afternoon, it will contribute to counteract the bad 
effects of confinement, and by giving a fresh impulse to the circulation 
and respiration, it will remove congestions, cool the head, warm the 
feet, and thus tend to refresh both body and mind. For similar rea- 
sons, it is well that more extended exercise should be taken twice rather 
than once daily, the second period being after the early tea, or before 
late dinner, as arranged under the head of Food (§§ 643-4). Those 
whose occupations are fatiguing either to body or mind, and who are 
obliged to dine late, may not have strength sufficient to bear the second 
period of exercise before dinner ; but they may be enabled by an hour 
or two of rest after this meal to take an evening walk, which Avill be 
found well-timed and refreshing, especially in the summer. Under all 
circumstances it is of importance to avoid much fatigue both before and 
soon after dinner. This being generally the principal repast, needs 
more than other meals, the undisturbed energies of the system for its 
digestion ; and if either the body is exhausted by exertion beforehand, 
or its energies are diverted from the digestive organs by exercise taken 
soon after the meal, the digestion will be disturbed, and various evil 
consequences may ensue. It is the chief objection to very late dinners, 
that after the toils of the whole day, the body is too much exhausted 
for the work of digestion, and stimulants are always needed to aid in 
the process, which they do but irregularly and imperfectly. 

663. The weaker or more delicate is the individual, the more neces- 
sary are the above-mentioned cautions against excessive or ill-timed 
exercise. The time to be devoted to bodily recreation will vary much 
with natural strength and habits, and the kind of exercise used. Fe- 
males and delicate persons will rarely benefit by more than from half 
an hour to three quarters of an hour's walk, or nearly double those 
periods of gentle horse exercise ; but robust males may find advantage 
in a considerably greater amount. 

664. Exercise varies in effect according to its kind. Walking, al- 
though giving some action to most of the muscles of the body, chiefly 
exercises those of the lower extremities; and by increasing the circula- 
tion and perspiration, especially in that direction, it tends to derive 
from the head and chest, and to relieve congestions of these cavities. 
Riding on horseback gives more exertion to the loins, and by the regu- 
lar movements which it communicates to the viscera of the abdomen, 



MENTAL OCCUPATION AND DISCIPLINE. 445 

pelvis, and thorax, it promotes their circulation and functions ; it is not 
equally eft'ectual in equalizing the circulation in the head and extremi- 
ties, and in cold weather, especially, often causes headache, which may 
generally be prevented by taking measures to keep the feet warm. 

Some kinds of exercise which include alternate stooping and raising 
the body, such as digging and other occupations in the garden, are 
serviceable in promoting the action of the bowels and kidneys ; and the 
same remark will apply to various games of bowls. Rowing has the 
advantage of very generally and uniformly exercising the muscles of 
the whole body ; but unless it be practised with moderation, the simul- 
taneous pressure which it exerts on every part may prove injurious, by 
overstraining the organs of circulation and respiration (§ 64); and 
many proofs have come w^ithin my observation of the evil consequences 
of boat-racing. 

MENTAL OCCUPATION. 

665. Under this head may be comprised a short notice of the mental 
influences which most conduce to the maintenance of health. As with 
the corporeal functions, so with the mind, a moderate and equable ac- 
tivity, with some variety of excitement and relaxation, contributes to 
its well-being ; and inasmuch as the body is greatly under the influence 
of the mind (§ 66), the health of both is, therefore, equally promoted. 
The kind and amount of mental exercise must vary considerably, ac- 
cording to difl*erent circumstances of age, sex, temperament, capacity, 
and habits of the subjects. The topic is far too mde to be compre- 
hended in the very cursory ,2;lance which we can give to it, and it must 
sufiice to notice some variations of mental discipline adapted to these 
difl'erent circumstances. 

666. In infancy, the sentient and perceptive functions are active, 
the emotional feelings lively, whilst the higher, moral, and the intellec- 
tual faculties are very imperfect. Hence the sensitive excitability 
of this age, which becomes a frequent cause of disorder ; and to mode- 
rate this by various soothing expedients, as by gentle and lulling im- 
pressions on the senses, with timely resorts to varied amusing toys, and 
other objects to divert attention, and gently exercise the organs of 
sense and perception, is the chief aim at this early period. But as 
infancy passes into childhood, there is sufiicient development of moral 
feeling and understanding to supply farther means of control and direc- 
tion ; and although at this age it is equally necessary to avoid causes 
of fretfulness and passion, the principle of self-control and patience 
may now be properly inculcated by moral and religious instruction, 
enforced by a consistent example of kindness and justice in the conduct 
of those who manage the children. The mental, as well as the bodily 
powers, at this early age, have no endurance — they are soon fatigued ; 
and nothing can be more hurtful than to excite them too much, or too 
long, by games or scenes of amusement ; exhaustion, fretfulness, and 
bodily suffering are the common consequences of such excess, and dis- 
ease not unfrequently follows. A similar objection may be urged 
against too early or too prolonged attempts to educate the mind ; such 



446 



HYGIENICS. 



attempts anticipate the period at which the power of concentration, or 
sustained attention, is acquired, which it can be safely only by time 
and practice. Children precocious in intellect gain this power early, 
but this is a reason against its exercise, which would the more readily 
tend to strain the active faculties to a morbid degree. 

667. As the mental capacity becomes enlarged by equal and judi- 
cious exercise in ripening youth, it is adapted to longer and severer 
tasks, and in addition to the advantages of thus improving the intellect 
by extended occupation at this age, the moral emotions and animal 
passions, which now acquire strength, are hereby moderated and kept 
in subjection. A leading rule to be observed in all attempts to develop 
and regulate the mind is, to exercise its powers as equally as possible ; 
the natural tendency is, that those powers which are constitutionally 
strongest should overrule and weaken others, and this applies to the 
impulses of moral feeling as much as to intellectual capacity. A main 
purpose of education is to prevent the inequalities, by exercising the 
weaker powers, and judiciously restraining those which unduly predo- 
minate. Herein education includes not the mere communication of 
knowledge, but the discipline of the heart and mind ; the subjugation 
of evil and useless inclinations and propensities, and the direction of 
the attention or activity of the intellect to objects that are profitable 
and improving. The influences by the aid of which this discipline 
may be exercised are manifold, and must, in some degree, vary with 
the age and with the character of the individual. In childhood, respect 
and love towards parents or others exercising authority; in youth, the 
same feelings confirmed and cultivated by the convictions of the under- 
standing now giving increased spontaneity of thought to the individual ; 
and in all ages, the constraining and elevating influence of religion in 
supplying the highest motives and rules for the conduct of thinking 
and responsible beings ; these are the great leading instruments through 
w^hich mental discipline is safely and eff'ectually appli&d. But other 
and less dignified motives are often equally powerful, such as vanity, 
pride, ambition, rivalry, and the like ; and although they prove the 
failing of the human mind from a standard of perfection, and, unless 
controlled, may become exaggerated into vice, yet under restraint they 
may be usefully enlisted on the side of mental improvement. 

668. When youth ripens into adult age, although technically speak- 
ing education is complete, the discipline and culture of the mind (which 
are the objects of education) are still to be carried on with all the 
activity proportioned to the full development of the faculties and pas- 
sions. This being the period at which the authority of parents or 
seniors is more or less relaxed, and the individual is of age to take full 
responsibility on himself, it is of the utmost consequence that his ma- 
ture powers should be directed in a career which may promote his 
present and permanent welfare; and much, in regard to his future 
health, depends on the possessing such ascendency of mind over body, 
of moral over animal feelings, as may secure the establishment of 
wholesome habits of wisdom and temperance. The subjugation of gross 
appetites ; the subordination of all turbulent or violent moral and 
mental emotions ; the cultivation of the gentle and calming feelings 



MENTAL OCCUPATIOX AND DISCIPLINE. 447 

fostered in domestic life or in refined social intercourse; and the regu- 
lar but moderate application of the intellectual powers to some definite 
object or set of objects worthy of their pursuit; — are items of mental 
discipline becoming the age of maturity, and if steadily practised can- 
not fail to conduce, not only to the health and endurance of both mind 
and body, but also to their lasting comfort and happiness. It is true 
that many difficulties beset the beginner in his endeavors to follow such 
rules; many struggles against the inferior part of himself; much 
exercise of patience and forbearance in regard to others ; a frequent 
practice of self-control in avoiding the temptations of excitement and 
intoxicating amusement ; and a constant vigilance over the mind, to 
restrain it equally from wandering into by-paths away from its proper 
road, and from lapsing into desultory abstraction or indolence; and 
these impeding forces within, ai'e often prompted or seconded by not 
less formidable obstacles without, thrown up by the multitudinous and 
ever-rising temptations and trials of life — never absent, but often 
peculiarly besetting its anxious and unsteady commencement. iSeed 
we say, then, that the efforts should be proportioned to the difficulties? 
and, with the full and rational exercise of human means, but with 
humble and faithful dependence on more than human guidance and 
strength, these efforts willnever prove unsuccessful. 

669. But it is our more special object to indicate the modes in which 
reciprocally the mind and body may promote each other's health; and 
■which may be summed up in the Platonic axiom that they should be 
well balanced in their exercise and activity. The undue or too pro- 
longed occupation of the mind with deep study or thought abstracts 
the supply of blood and of vital energies from the bodily functions : 
these suffer and fall into weakness and disorder, whilst the nervous 
system, the material organ of the mind, is ultimately exhausted by the 
continued excitement, and refuses to perform one of its manifold func- 
tions ; hence stupor, paralysis, or organic weakness of some kind mav 
ensue; or others may retain a morbid erethism or irritation in the midst 
of general weakness ; and delirium, spectral illusions, sleeplessness, 
tremors, spasmodic or painful affections may be the consequence. 
Mental idleness, on the other hand, not only weakens the intellect by 
disuse, but, by inducing habits of indolence and self-indulgence, pam- 
pers the body and perverts its proper functions, degrading them to an 
approximation to bruta.1 or even vegetable life. Moderate and well- 
timed exercise refreshes the mental powers, and enabling them to 
apply with renewed vigor, increases their permanency and sphere of 
action. So likewise, pleasing mental impressions, as from beautiful 
scenery, congenial associations, and interesting pursuits, heighten the 
benefits of bodily exercise, and give all the faculties that renascent 
energy which is well expressed by the term recreation. A similar ad- 
vantage accrues from varying the kind of mental occupation; thus 
music, drawing, amusing games, and light reading, are to many, more 
effectual than absolute rest, in refreshing the mind after severe study 
or close application. In like manner, intellectual tasks of different 
kinds may be profitably alternated with each other, as the several 
muscles of the body are more beneficially exercised in succession than 



448 



HYGIENICS, 



all at once (§ 664). Analogous rules may be applied to the moral 
emotions, so far as they can be placed under the direction of the indi- 
vidual ; and there is in most energetic minds somewhat of a natural or 
habitual succession of high and low spirits, of lights and shadows in 
the mental hemisphere, which, however trying and hazardous it may 
be in extremes, when occurring in moderation, gives a renewed vigor 
to thought which is wanting in minds of more perfect placidity. 



SLEEP. 



670. It would be quite superfluous to expatiate on the health-giving 
influence of a due amount of tranquil sleep. It is the chief means of 
recruiting the exhausted energies of the animal functions ; and some of 
the causes and consequences of its failure have been already noticed 
among the causes and elements of disease (§§ 23, 56^ 64, 154). It ap- 
pears to consist in a more or less complete suspension of the cerebral or 
sensorial functions, Avith an incredfse of the medullary and organic nerv- 
ous influence ; and we have suggested that a modification in the distri- 
bution of the blood through the nervous centres may be instrumental in 
thus periodically reducing the activity of those parts which are not so 
essentially concerned in the maintenance of life (§ 153). The sensorial 
functions are only impaired, not completely suspended, for a proof of 
their partial continuance during sleep is to be found, not only in dream- 
ing, but also in the voluntary movements, often performed to remove 
uncomfortable sensations, and even in the act of awaking when such 
sensations attain a certain degree of intensity. 

The approach of sleep is announced by the feeling of drowsiness, 
which consists of a dulness of sensation, perception, and thought, and 
an indisposition to exertion. Gaping and yawning, although symptoms 
of sleepiness, result from efl"orts to resist it ; they seem to be move- 
ments designed to throw certain muscles, especially in the throat and 
neck, into a state of tension, during which the sensation of drowsiness 
is for the moment increased to a degree rather agreeable than other- 
wise, but followed by its diminution. It is very probable that these 
movements tend to re-excite the slackening cerebral circulation by 
momentarily impeding it, and then allowing it to flow again with aug- 
mented force ; a process like that of flushing. Sleep closes the rela- 
tions of the senses to all moderate impressions of the external world, 
and suspends almost all voluntary movements, among which are to be 
reckoned those supplementary to the process of respiration (§ 628). 
The respiration is therefore rendered less frequent and more pro- 
longed than when awake, and the pulse is also lowered. The circula- 
tion and changes of the blood being thus reduced during sleep, there 
is less power of maintaining animal heat ; hence the chilliness of per- 
sons during and after sleep, and their susceptibility to cold, unless 
better protected than usual by clothing. Hence, too, the relaxation of 
the skin after slight febrile excitement, which during sleep yields to 
perspiration. 

671. The circumstances which promote sleep are chiefly those wdiich 



SLEEP — PROMOTIXa INFLUENCES. 449 

impair the activity of the animal functions, and those which withdraw 
all causes of excitement to mind or body. A moderate degree of bodily 
and mental fatigue ; the absence of all uneasy sensations ; a comfort- 
able posture, giving the most complete rest to the limbs and voluntary 
muscles ; a freedom from the feeling of either hunger, thirst, or reple- 
tion, cold or heat; the periodic recurrence of a regular hour for repose, 
and the stillness and darkness of night — are favorable for the induction 
of sleep. In addition to these, which act negatively by excluding ex- 
citement, there are others which are sometimes found to promote sleep 
by causing gentle and monotonous sensations or ideas which have the 
effect of lulling into somnolence ; such, for example, as the various ex- 
pedients for hushing infants to rest, by rocking, patting the back, sing- 
ing, &c., and with adults, like soothing devices sometimes succeed ; as 
by gentle friction, reading, prosy talking, and other dull impressions 
on the senses which slightly tire without excitement. These probably 
operate by diverting the attention from other feelings or noises, which 
occurring occasionally, tend to disturb. The passes of mesmerism 
seem to act on the same principle. The expedient of counting or re- 
citing one's self to sleep owes its efficacy (which is but smallj to the 
abstraction of all attention to an uninteresting object. 

672. The influences which prevent or disturb sleep are for the most 
part the reverse of those last described. Any undue excitement or 
sensation of body or mind, whether of a painful or a pleasurable na- 
ture ; strong, sudden, or startling impressions on the senses ; uneasy 
postures ; extreme fatigue or exhaustion ; oppressed or imperfect 
breathing ; palpitation of the heart ; hunger, thirst, nausea, flatulence, 
and various other (often undefinable) sensations in the viscera ; ex- 
tremes of temperature ; coldness of the extremities ; irregularity in 
habits of getting rest ; — comprise the ordinary causes of sleeplessness. 
They operate either by directly exciting the sensorium to a degree 
inconsistent with the suspension of its functions, or by so much reducing 
or disordering the power of the medulla, that it is incapable of sustain- 
ing the respiratory movements without the aid of voluntary effort. In 
the former case positive pain, uneasy sensation, or exciting trains of 
thought, are present. In the latter there may be the desire to sleep, 
but no sooner does its commencement suspend the voluntary efforts 
by which the breathing is aided, than this process becomes imperfect, 
and the person starts with a feeling of oppression or impending suffo- 
cation, which his commencing dream impersonates into nightmare, 
or connects with the idea of being pursued by demons, falling down 
a precipice, or some such horrible catastrophe which entirely precludes 
the reality of sleep. Such are the sleepless hallucinations of deli- 
rium tremens and similar disorders, in which continued excitement of 
the nervous system has exhausted the energy that is required in the 
medulla for the maintenance of respiration and muscular tone during 
sleep. 

673. The loss of rest is so seriously detrimental to health, that to 
prevent it by hygienic means is of great importance ; and besides avoid- 
ing so far as possible the several causes of wakefulness just specified, 
bad sleepers should take heed to attend to the following directions for 

29 



450 



HYGIENICS. 



their regimen, rather than resort too hastily to hypnotic drugs, which, 
although sometimes useful and necessary as temporary expedients, lose 
their effect by habitual use, and produce other evil consequences which 
render their continuance improper. 

Bad sleepers should make a regular practice of early rising ; it may 
cost them some trial of strength at first; but if they would improve 
their sleep, they should seek it at the natural time, and not late in the 
morning when the excitements of the day begin. Their hours of meals 
and exercise should also be early and most regular (§§ 644, 662) ; both 
in order to promote that state of health most conducive to ease and free- 
dom from suffering, and also to secure the accomplishment of the pro- 
cesses of digestion and consequent excretion or eructation before night, 
which is the proper period for repose (§§ 643, 4). Exercise should be used 
as freely in the open air as the strength will permit without causing last- 
ing fatigue ; and if the strength do not bear walking or riding, driving 
or sitting out in the open air several hours in the day is an efficient 
means of promoting sleep by gradually and gently fatiguing the senses 
by the continued operation of light, air, and sound, whilst the organic 
energies are refreshed and invigorated by their salutary influence 
(§ 652). As the hour of retirement for rest approaches, every descrip- 
tion of exciting agency should be avoided. The latest meal should be 
taken at least an hour before bedtime, and tea, coffee and all vegetable 
matters apt to generate gas should be excluded from it. Weak per- 
sons and others under the influence of fatigue may often advan- 
tageously take a little wine or alcoholic mixture at this meal ; its opera- 
tion, which counteracts the exhaustion and nervous excitement induced 
by weakness, being composing and hypnotic (§§ 64, 155). All active 
exertion of body or mind should be carefully avoided at this time. 
Subjects of conversation or reading should be commonplace or tran- 
quillizing, neither requiring much attention nor exciting to the feelings 
or imagination. The very preparation of undressing should be simpli- 
fied as much as possible, and all superfluous items or general washing, 
&c., should be postponed until the following morning. Much might be 
said about the construction of the bed and its appendages, and the pos- 
ture best suited for tranquil repose ; but this is not the place for such 
details, which may be comprised in the general direction that all is to 
be made as comfortable as possible, without relaxing by excessive soft- 
ness or abundance of covering. A soft upper mattress of hair, or wool 
and hair, is always preferable to a feather-bed, not only in being less 
relaxing, but also in its giving a more elastic and even support to the 
body and limbs, and preventing that sinking in of the body which 
fatigues a weak back by bending it. The posture most easy for the 
person is on the right side, which affords to the two weightier organs, 
the liver and heart, support which prevents them from pressing on 
the hollower viscera. The various expedients for inducing sleep by 
repeating lines of poetry, counting, and numbers, and other means 
which act by diverting attention from exciting trains of thought, seldom 
succeed with the really wakeful. The plan devised by the late Mr. 
Gardner, and published by Dr. Binns in his Anatomy of Sleep (p. 391), 
has not proved more successful in my experience. It is founded on 



SLEEP — PROMOTINa MEANS. 451 

the same principle of abstracting the attention, by directing the mind 
to the imaginary vision of the breath issuing from the mouth during 
expiration. A device which I have found to answer better, is founded 
on the attempt to imitate the mode of breathing of a person during 
sleep, by making the respirations, particularly the expirations, lower 
and more prolonged than usual, and giving to them somewhat of a 
sonorous character from the relaxed and therefore imperfectly open 
state of the glottis. This often excites a feeling of drowsiness, pro- 
bably by gently retarding the return of blood from the brain ; and this 
drowsiness may soon end in sleep ; but it frequently happens with this, 
as with all other voluntary attempts to procure sleep, that the contin- 
uance of the effort breaks the spell by the awakening effect of excited 
attention, and this objection especially applies to the first attempts to 
practise such invocations of Morpheus. The expedient recommended 
by Dr. Franklin to restore sleep that has been broken, by rising and 
shaking the bed, with the view to change its air, is sometimes success- 
ful, particularly in hot weather. 

674. The amount of sleep most conducive to health varies consider- 
ably with age, sex, employment, and constitutional and habitual pecu- 
liarities. Infants pass the greater part of the day as well as the night 
in sleep ; and children, up to the age of six years, generally require at 
least twelve hours of repose, besides an hour or more in the middle of 
the day. At about this age, the sleep at noon may be discontinued, 
but the night sleep can hardly be abridged with advantage, until about 
the tenth year, and then only to a moderate extent, until the period of 
puberty, after w^hich it is generally proper gradually to reduce the 
period of rest to nine or ten hours ; and no farther diminution is expe- 
dient until the cessation of growth, when an another hour or two may 
be taken from it. The average amount of daily sleep beneficial in adult 
and middle ages may be stated at eight hours. In more advanced life 
this extent of sleep is not less serviceable where it can be procured ; 
but at this period the capacity for sleep usually diminishes, and wake- 
fulness or disturbed sleep is a common complaint of old age. Atten- 
tion to the precautions before recommended (§ 673) will, however, often 
restore it ; and even if they do not sleep, aged persons require an in- 
creased period of time in bed, for the sake of warmth and rest, which 
their reduced calorific and muscular powers render more necessary. 

Females commonly stand in need of more sleep than males, and dur- 
ing pregnancy and lactation additional rest is especially demanded, to 
assist the supplementary nutritive processes brought into operation in 
these conditions. In such cases, too, the loss of sleep is attended and 
followed by peculiarly injurious results, manifest especially in the nerv- 
ous system and general nutrition, in the form of mental derangement, 
impaired vision, deafness, paralysis, palpitation, convulsions, tremors, 
anorexia, wasting, diarrhoea, &c. Under these circumstances, a chief 
object of the treatment will he to procure sleep, and in addition to regi- 
menal means before suggested, nervous sedatives or hypnotics of the 
least depressing kind are required. Persons convalescent from acute 
diseases, or otherwise weakened and reduced, require and generally 
obtain more sleep than in ordinary health, and it is so efficient an in- 



452 HYGIENICS. 

fluence in the promotion of recovery, that artificial means are sometimes 
properly used to procure it. So, likewise, those who use much active 
exertion need a longer period of repose than those who are sedentary ; 
.and the same rule is applicable to persons whose minds are greatly ex- 
ercised ; but as mental excitement does not dispose to sleep to the same 
degree as bodily fatigue, it is the more important that all persons whose 
intellectual powers are much strained, should also use such exercise as 
may maintain the balance and promote the return of sleep. 

675. Salutary as is the operation of sleep in its due time and de- 
gree, it may prove injurious if indulged in to excess and at improper 
seasons. Too much sleep slackens the circulation, diminishes excre- 
tion and muscular nutrition, and causes general plethora or partial 
congestions, and in those disposed, promotes the accumulation of fat. 
By inactivity it weakens the muscular and sensorial powers, and gives 
an ascendency to the medullary function ; hence a tendency to spas- 
modic and other nervous disorders of the system, which may farther 
declare themselves in fits of hysteria or even epilepsy. In persons 
liable to this class of disorders, a judicious abridgment of sleep is often 
very beneficial ; and it is best effected by gradually establishing the 
habit of early rising. Undoubtedly the most fitting time for sleep is 
the night, and although in these latitudes the nights are in summer 
too short, and in winter too long for the amount of needful repose, 
yet the more nearly this is assigned to the period when darkness and 
silence warn to rest, the better for the permanent comfort and well- 
being of the body. On the score of health, then, it is recommended 
that even adults should retire to rest, in summer especially, as many 
hours before midnight as can be spared after night closes ; in order 
that they may be enabled to rise at or as soon after sunrise as they 
have had their proper complement of sleep. But, inasmuch as the 
usages of society and the business of life often make unavoidable de- 
mands on the night hours of many persons, the compromise of retiring 
one hour before midnight should be enjoined for the sake of health, 
and accompanied with an exhortation to early rising, enforced by a 
description of the refreshing and invigorating influences of the morning 
air, with all its exhilarating concomitants of light and sounds. 



EXCRETION. 

676. The absolute necessity of a sufficiency in the processes of excre- 
tion for the maintenance of health, has been made apparent by the nu- 
merous instances cited in the preceding pages, in which their failure 
has led to the production of disease (§§ 68, 248-254, 385, &c.) ; and 
although such instances commonly constitute such cases of disease as 
require the application of medicinal means, yet the regularity and com- 
pletion of the processes of elimination may be so far promoted by com- 
mon regimenal measures as to deserve a place among hygienic elements. 
Depending, as excretion does, on the activity of the processes — of cir- 
culation, which regulates the supply of blood to the secreting organs ; 
of respiration, which improves the properties of that blood by renewing 



EXCRETION. 453 

its chief chemical agent, and of assimilation, Tvhich adds to its materials; 
of muscular contraction, -which effects the expulsion of the excremen- 
titious matter ; and of sensation, T^•hich takes cognizance of the need of 
its evacuation — it might be anticipated that the proper performance of 
this office (excretion) Tvill much depend on the vigorous condition of 
these several processes, which with it compose the sum of the general 
health. Hence many of the hygienic measures that have been recom- 
mended as contributing to sustain these several processes, are likewise 
efficient in promoting that of excretion. Thus a proper regulation of 
food, solid and liquid (§§ 642-§44), and a regular use of exercise 
(§§ 660-662), are important means of favoring all the excretions ; and 
the functions of the skin and kidneys, and, in less degree, those of the 
liver and intestines also, are influenced by clothing^ temperature^ air, 
and sleep (§§ 646-649, 652-655). 

It will be sufficient to indicate a few of the more available means 
which are found useful in regulating the actions of the hoivels^ kidneys, 
and sMji in health. 

677. No circumstance tends more to promote the regular action of 
the intestines, than the punctual habit of daily devoting a fixed and 
sufficient time to their evacuation. Medical writers have long insisted 
on the importance of punctuality in attention to this office ; but they 
have not recocrnized the necessity of dedicatino; an amount of time suffi- 
cient for its proper completion, yet with persons of costive habit this is 
not a secondary consideration. In persons whose bowels act readily, 
an efficient peristaltic action forwards the feculent matter in consistence 
and quantity fitted for prompt and easy expulsion at the accustomed 
time ; but with those of torpid bowels (and they constitute a very 
numerous class, even among healthy persons), the excrement is more 
solid and the intestinal movement more tardy, and instead of being all 
in the rectum ready for delivery at the appointed hour, more or less of 
it may be still lagging behind in the sigmoid flexure, or above it, and 
cannot be discharged by a momentary eff'ort. Nor will violent strain- 
ing (which is, moreover, injurious in other respects (§§ 64, 289), pro- 
perly aid in the process. Repeated gentle and sustained abdominal 
contractions, aided, if necessary, by kneading pressure or friction 
downwards in the left iliac region, in the direction of the sigmoid 
flexure, with some variation in the position of the trunk, are the safest 
and most efficient means of accomplishing this object, but they require 
the sacrifice of a few minutes of time ; and if the end were not worth 
this sacrifice, I would not shock the delicacy of my readers by allusion 
to so disgusting a subject. These expedients are more easy and natu- 
ral, and less injurious than the use of enemata ; of which even the 
simplest kinds, if employed habitually, injure the tone of the bowel, 
and impair its natural action. 

678. Other means may be mentioned as serviceable in ordinary health 
to promote a regular and sufficient action of the bowels, such as the use 
of brown or rye bread, instead of white ; taking at night oatmeal por- 
ridge ; ervalenta or lentils ; white mustard seed ; stewed prunes ; tama- 
rinds; baked apples, and the like; all of which act by adding either a 
mechanical or chemical irritant to the feculent mass, and may prove 



454 HYGIENIC^. 

objectionable by irritating too much and otherwise disordering the ali- 
mentary canal. The same objection applies to the addition of toasted 
bacon to breakfast, and that of a quantity of fruit to dinner. A more 
harmless, and sometimes more efficacious expedient, is that of drinking 
a large draught of cold spring-water at first rising, which is useful for 
other purposes likewise. With some persons malt liquors promote the 
action of the bowels. A walk before breakfast for the more robust, 
or a walk or ride immediately after that meal for others, often con- 
tributes to the same end ; and in some instances such exertions as 
particularly bring into action the abdominal and other muscles of the 
trunk, such as digging, or other occupations in gardening, prove more 
effectual. 

679. Lastly, we must not omit mention of the habitual use of gentle 
aperient medicines, as the safest and most efficacious means of securing 
an adequate intestinal action in persons whose sedentary occupations 
or other circumstances absolutely prevent their adopting more strictly 
hygienic measures for the accomplishment of the same purpose. Un- 
doubtedly, it is preferable to avoid the constant use of medicine, if 
dietetic or regimenal management can be so conducted as to supersede 
it ; but much observation has convinced me that this cannot always be 
effected, and then as a prophylactic or hygienic resource, a little daily 
pill is preferable to the practice of loading the stomach with indigest- 
ible matter with the object of stimulating the lower bowel. The drugs 
which commonly answer best as habitual laxatives, are rhubarb and 
aloes, both of which in their bitter properties combine somewhat of a 
tonic with their aperient action. Aloes is the most efficacious aperient, 
and if properly managed, does not lose its effects, even after many 
years of daily use. I know of an instance in which it was continued 
for fifty-seven years with unquestionably beneficial results, and the 
individual, in spite of very sedentary habits, retained uncommon vigor 
of body and mind until within a year of his death, which occurred at 
the age of eighty- seven. By far the best mode of administering aloes 
as an habitual aperient, is in combination with a little mastic, and 
made into a mass with alcohol, which renders the pill less soluble in 
the stomach, and, therefore, more capable of acting on the lower part 
of the canal. The combination which I commonly use, consists of 
three parts of socotrine aloes, with one of mastic powder, made into a 
mass with alcohol; two or three grains of this are to be taken at din- 
ner or at bedtime daily. This pill has no tendency to excite hemor- 
rhoids, provided an occasional dose of blue pill be taken to promote a 
sufficient action of the liver. In several instances I have found it 
operate more comfortably enjoining with it a few grains of inspissated 
ox-gall. In weakly persons, a grain of sulphate of iron or quinia 
may be added with advantage. 

680. The excretion of urine is less generally an object of solicitude 
than that of alvine function, yet it is remarkable how usually persons 
as they advance in years have their attention drawn to it, often from 
experiencing the discomforts of its regularity or deficiency ; and such 
irregularities are undoubtedly an important element in a vast proper- 



EXCRETION — URINE. 455 

tion of diseases, whether serious or trivial. It would occupy too much 
time to advert at length to disordered excretion of urine here ; in fact, 
the subject has been considered in almost every part of the present 
work ; and it must suffice to mention a few common hygienic influ- 
ences by which the urinary excretion may be promoted or rendered 
more free. 

The abundance of urine, and therefore usually its clearness and 
moderate specific gravity, will be generally proportioned to the amount 
of fluid ingesta ; but the increase is more sure, when fluid, especially 
water, pure, or with a very slight addition of vegetable or animal 
nutriment, is taken on an empty stomach. Thus, a large draught of 
spring-water drunk at first waking in the morning, or an hour before 
dinner, is almost surely followed by a free flow of clear urine. This 
result is promoted by such moderate exercise as excites the heart's 
action without causing free perspiration. Some kinds of exercise pecu- 
liarly augment the secretion of the kidneys ; especially those bringing 
the loins into action, as gardening, and trotting on horseback ; and 
these modes of exercise may therefore be recommended to those whose 
secretion is defective, especially those liable to lithuria ; for by increas- 
ing the watery constituent of the urine, there is less risk of any deposit 
taking place in the urinary apparatus. But similar means, if regularly 
used, are useful also in gouty and rheumatic habits ; and they appear 
to establish an increased elimination of solid matter, as well as of 
water, by the kidneys ; and in this respect their operation difi'ers from 
that of medicinal diuretics, which, unless very judiciously administered, 
excite for the time, and leave the secreting power exhausted afterwards. 
This is the chief objection also to certain diuretic beverages in common 
use, but as temporary expedients they are useful; such as gin, Hollands, 
or whiskey, diluted with water ; spruce beer ; imperial drink (water satu- 
rated with bitartrate of potass, sweetened and flavored), leek or onion- 
broth, barley-water, linseed, and tamarind-tea, Seltzer water, &c. 
Grapes, currants, and other ripe subacid fruits, also may be occasion- 
ally useful in the same way. 

681. The regular evacuation of the bladder, when distended to a 
certain degree, is prompted by the sensation excited, but in very 
various degrees, in diff'erent individuals ; some, either not feeling, or 
resisting the want, and others yielding too frequently to its impulses. 
The latter extreme is inconvenient, especially from its disturbing sleep 
at night; but the habit of too long retaining the urine may prove per- 
nicious in various ways formerly specified (§ 68), and should therefore 
be carefully avoided. In circumstances interfering with a proper ob- 
servance of this caution, its urgency may be diminished by limiting 
the amount of liquids taken, and by promoting the cutaneous excre- 
tion by warm clothing and external warmth. 

682. The full purposes of the perspiratory secretion are not entirely 
known ; but its uses are recognized — in evacuating from the superficial 
vessels superfluous water, acid, and oily matter, under the distending 
or exciting influence of prolonged heat or exertion ; intending by its 
evaporation to cool the surface thus heated, and by its relaxing efi*ect 



456 HYGIENICS. 

on the tissues to remove tlie iritation of distension or obstruction ; and 
by the same softening operation to render the skin more pervious to 
the chemical action of the air on the blood and to the vital influences 
reciprocated between the blood and the tissues. 

The excretion of the sMn has been mentioned to be materially in- 
fluenced by clothing^ exercise.^ and temperature and air^ and these are 
the chief means by which it is variously afi"ected in healthy persons. 

Other hygienic measures for promoting the action of the skin, are 
bathing, washing, and friction. The chief operation of all these agents 
is on the skin, as an instrument of circulation and secretion ; and in 
proportion as they are extensively applied, they may exercise an influ- 
ence on the whole system. Thus warm bathing of the whole body, as 
it increases the amount and motion of blood in the cutaneous vessels, 
and the perspiration from them diminishes the supply to internal or- 
gans, and consequently the amount of their secretions. If continued 
long, or repeated frequently, general weakness will result, the surface 
remaining in a relaxed state. The same objection does not apply to 
the occasional use of the warm bath, or the daily practice of washing 
the whole surface with tepid sponging or shower-bath, followed by fric- 
tion ; and these are highly salutary means of keeping the skin in a free 
and active condition well suited to persons of languid circulation. But 
in the majority of healthy subjects, this object is better obtained by 
cold washing, and in the robust, even by cold bathing, in shower or 
plunge, which indirectly excites the functions of the skin by constrict- 
ing its vessels, and thus throwing the blood on internal organs, and by 
impression on the incident nerves, causes the excitement of reaction, 
which soon restores the superficial circulation in redoubled force, with 
its concomitant redness and glow (§ 80). This reaction is much pro- 
moted by vigorous friction of the whole surface with coarse towels or 
horse-hair gloves, and this operates not only by stimulating the cuta- 
neous vessels and glands, but also by the muscular exertion exciting 
the heart to stronger and more frequent contractions ; for the same 
reason, other exercise, as in a brisk walk, is often useful. If, after cold 
bathing, the reaction is incomplete, and the skin remains pallid, chilly, 
and contracted, it may be inferred that the cold has been too long ap- 
plied, and has permanently impaired the functions of the skin, and left 
the internal organs more or less congested. Or, if, after complete 
reaction, an unpleasant fatigue, languor, chilliness, headache, or other 
uncomfortable sensation remain, it is a proof that the cold and subse- 
quent reaction have been too depressing or exhausting ; in either of 
these cases tepid bathing or washing is to be preferred. The vapor- 
bath, with shampooing and various aromatic and stimulant applications, 
although a powerful remedial agent in cases of disease (especially chro- 
nic rheumatism and its consequences), is too exciting and exhausting 
to be recommended as a means of preserving health. 

[683. A few general rules on the hygienics of sick persons will not 
inappropriately close this chapter. 

Patients laboring under acute disorders should be placed in large, 
dry, and well-ventilated apartments. The temperature of the room 



HYGIENIC RULES FOR THE SICK. 457 

should be equable and moderate ; tlie amount of light must be regu- 
lated by the character of the disease. When the air is contaminated 
by noisome exhalations, fumigations may sometimes be advantageously 
resorted to. If the room in which the patient is taken ill be small, 
badly ventilated, or damp, he should be removed, if possible, into a 
larger one, free from these inconveniences, as the risks of moving, even 
in severe febrile affections, are less than is usually imagined (Chomel). 

684. Great cleanliness should be strictly maintained, and for this pur- 
pose the linen should be frequently changed ; but not so as to fatigue the 
patient. It may be done even whilst the patient is sweating copiously, 
and great comfort will result. To effect this, warm cloths, passed un- 
derneath the shirt, should envelop successively the legs, thighs, abdo- 
men, chest, and even the neck, so that the arms alone will be momentarily 
exposed to the air. Patients should neverbe permitted to sleep on feather- 
beds, without an intervening mattress. It is often necessary to employ 
auxiliary means to receive the excretions, impermeable cloths to pro- 
tect the bed linen, and cushions to obviate pressure on certain parts of 
the body. The position of the bed should vary according to the nature 
of the disease. 

G85. The employment of suitable aliments and drinks in acute affec- 
tions is of great importance, and adds materially to the comfort of the 
patient. There are two extremes to be equally avoided : nourishing 
patients too much, and not nourishing them enough. Hippocrates 
thought it safer to err on the side of excess, than for patients to ob- 
serve total abstinence. In acute febrile affections, you should observe 
a just medium. Proscribe all kinds of solid aliment, but permit the 
use of fluids slightly nutritious, such as farinaceous articles, light 
broths of veal and chicken, the juicy fruits, etc., when the febrile move- 
ment is not too high. In the low forms of fever, when the strength 
has to be supported, it is indispensable to nourish the patient, and 
severe adynamic symptoms may often be prevented by timely nourish- 
ment. The injudicious use of food has the power, it has been remarked 
by a celebrated authority, of nourishing the disease, and not the 
patient. 

686. It is of immense importance in all acute disorders that the ex- 
cretions of the patient should be immediately removed. Perspiration 
chills the body ; the urine and fecal matter, already compromised, are 
disposed to speedy decomposition, and impart noxious qualities to the 
air. When involuntarily excreted, their contact with the body is posi- 
tively injurious, by provoking eruptions, excretions, and even sloughing. 

68T. In acute diseases, repose and quiet are indispensable. Syden- 
ham thought that fever patients should be made to rise every day, and 
that doing so obviated the tendency to delirium. There is no doubt 
but that patients should be daily placed in an arm-chair, or on a bed, 
according to their strength, in order to allow their own bed to be made ; 
if this cannot be done, they can be removed to another portion of their 
bed, whilst the necessary change is made. When a patient is too 
feeble to change his position in bed, it should be done for him fre- 
quently; it adds materially to his comfort, prevents the formation of 



458 



HYGIENICS. 



sloughs, and obviates the tendency to pulmonary congestion, so frequent 
in protracted fevers. 

688. Sleep is generally a favorable symptom in acute diseases. 
Everything vv'hich, by acting on the senses, or the moral of the patient, 
will prevent it, should be obviated. From the same motives sleep 
should not be broken to administer medicines, without the necessity is 
urgent. Sleep may sometimes be induced in convalescence, by causing 
the patient to rise, and readjusting his bed. Gentle friction with the 
fingers on some part of the body disposes to somnolency. 

689. The sensations, the emotions, and intellectual faculties, all de- 
mand, in a special manner, the attention of the physician. The removal 
of all moral or mental circumstances, which either have produced or 
keep up the morbid condition, is important. Conversation should be 
banished from the sick chamber ; when low, it is annoying ; when loud, 
fatiguing and exciting. The influence of the passions of the mind is 
so great that nothing should be neglected to give them a favorable turn. 
To this end the physician should obtain and deserve the confidence of 
the patient, (careful attention and great interest will frequently accom- 
plish this), and he should be careful that nothing in his manner or 
speech should betray anxiety or uneasiness. Patients generally re- 
ceive with satisfaction assurances of the successful termination of their 
complaint from their physician. The fear of death adds materially to 
the danger, in a majority of instances, and " the physician," says Cho- 
mel, " who allows his patient to suspect the danger of his position, 
diminishes his prospects of recovery." Sir H. Halford, in some judi- 
cious remarks on the duty of a physician, in withholding from, or com- 
municating to, a patient the probable issue of a disease displaying 
mortal symptoms, says, " that the first duty of a physician is to pro- 
tract the life of a patient by all practical means. ""^ The probability of 
a fatal issue should, therefore, be communicated to the friends, and, 
except under very peculiar circumstances, never to the patient. 

690. In chronic diseases, hygienics are of immense utility. Change 
of habitation and climate, voyages by land and sea, a sojourn at some 
fashionable watering-place, &c., often succeed in restoring health when 
all other remedial measures have failed. — C] 

^ Lond. Med. Gaz. toI, vii. p. 602. 



APPENDIX 



THE PATHOLOGY OF GOUT AND ALBUMINURIA. 

In addition to the facts mentioned in Sections 13 and 14 of Chap. II., 
I may state that Dr. Garrod has, in several other cases of gout, detected 
lithate of soda in very appreciable quantity in the blood, whilst at the 
commencement of a fit of gout there is a marked diminution of it in the 
urine. On the abatement of the attack, the lithic acid, or its com- 
pounds, appears in increased quantity in the urine, and that in the 
blood is therefore diminished. This exactly accords with the view that 
I have always taken of the nature of acute gout in common with other 
febrile diseases excited by a morbid matter in the blood, that the 
febrile excitement is the result of a reaction which may succeed in 
eliminating the oifending matter, and in relieving the system from its 
influence (§§ 254, 448). It appears farther, from Dr. Garrod's 
analyses, that slight traces of lithic acid may be detected in the blood 
of persons who are comparatively healthy, or who are affected by other 
diseases than gout; but in this malady the amount is much greater. 
My clinical assistant, Mr. Edward Palmer (on whose accuracy I can 
fully depend), has separated crystals of lithic acid also from the blood 
of two of my patients suffering from degeneration of the kidneys with 
albuminuria. In acute rheumatism, Dr. Garrod found no increase of 
lithic acid in the blood; but I have little doubt, from its abundant 
appearance in the urine in many cases during the decline of this dis- 
ease, that something analogous and easily convertible into it, does 
exist in the blood of rheumatic patients, and that farther researches 
will establish the chemical relation between two diseases which are 
known to border so closely on each other, in regard to their symptoms 
and treatment. 

Some of the above-mentioned researches, and others made expressly 
by Mr. Palmer, have farther illustrated the pathology of albuminuria, 
as explained at § 385. In the case of a female, the urine voided in 
twenty-four hours amounted to 20 oz. sp. gr. 1018, containing albu- 
men, measuring when coagulated three-fourths of the depth of the urine 
in the tube. The whole amount of solids did not exceed 372 grains of 
which, 88 grains were albumen, and 140 urea. The patient died coma- 
tose five days after, and lithic acid, as well as abundance of urea, was 
found in the blood. In another case the whole amount of urea excreted 



460 THE CAUSES AND TREATMENT OP 5CUEVY. 

in tTventy-four hours did not exceed 103 grains, -whilst no less than 416 
grains of albumen were passed. 

The following table represents the amount of solids contained in the 
urine of a woman admitted into the hospital with recent anasarca and 
albuminuria, and treated bv the remedies mentioned in § 395. 



Solids in Urine. 
Not. 4th . . 597 arains, — At this date the albumen half filled the tube. 
565^ — 
589 — 
934 — 

q^rj^^-y ( Anasarca now remoyed : and albumen 'iisappeared 

\ from the taine. 
710 — 
1041 — 



5 

8 
9 

13 



THE CAUSES AXD TEEATMEXT 01 SCURVY. 

Except a brief allusion in § 68, little has been said in the text on 
the nature and treatment of scurvy ; and this was because the subject 
remained involved in much obscui'ity, and had received little light 
from pathological research. A paper has been just published bv my 
colleague and former pupil, Dr. Garrod, which propounds a view of the 
real cause of the disease which is at once so plausible, and so directly 
suggestive of a simple and effectual remedy that it deserves notice in 
this place. On carefully comparing the kinds of food, the use of which 
have been observed to be followed by the occurrence of scurvy, with 
the dietetic and medicinal articles which have best repute as being 
antiscorbutic, Dr. Garrod found the former to be remarkably deficient 
in potash, whilst all the latter contain it in considerable quantity. 
Thus, on analysis, he found oatmeal, rice, peas, white flour, cheese, and 
salted meat to contain much less potash than potatoes, fresh meat, milk, 
and the juice of limes, lemons, and oranges, which are reputed to be 
antiscorbutic. He farther discovered in the few scorbutic patients 
whom he had the opportunity of seeing, a marked deficiency of potash 
in the blood or urine ; and the treatment by a few grains of a salt of 
potash was followed by speedy recovery. Dr. Garrod considers that 
potash is essential as a normal constituent of muscular structure, and 
that its nutrition must fail when no longer supplied with this alkali. 
^'Both soda and potash are constant constituents of the animal body, 
and it appears that they are not capable of replacing each other : for 
example, we always find the potash to exist in large quantities in the 
ash of muscle, and soda in very small quantities (Berzelius, Liebig') : 
in the ash of blood we find the relation reversed. It appears also that 
the muscular system requires the presence of potash, and we should 
therefore expect to find that when there is a deficient supply of this 
base, the efi'ect would soon be manifested in the functions of that sys- 
tem. This we find to be the case in scurvy ; without any amount of 
wasting of the body, we find marked muscular debility, and this is 
perhaps one of the earliest symptoms of the disease." {Monthly Jour- 



ON THE USE OF CHLOROFORM. 461 

nal of Medical Science^ Jan. 1848.) *I may add that the fatty degene- 
ration of the muscles (§ 545) has been observed to occur in protracted 
scurvy, probably from the same want of this normal constituent of 
muscular tissue. 

Should this ingenious theory be confirmed by subsequent research, 
it may prove of great value in its application to practical medicine, 
not in the treatment of scurvy only, but in other diseases attended 
with muscular debility, and a disposition to passive hemorrhage. It 
may be remarked that, in Mr. Blake's experiments, the salts of potash 
in solution injected into the veins, caused a firm coagulation of the 
blood, whilst those of soda had a contrary efi"ect (§ 214), note). The 
bitartrate of potash, too, is reputed to be a remedy for hemorrhage. 



ON THE USE OF CHLOROFORM. . 

The important discovery by Dr. Simpson of the power of the vapor 
of chloroform, as an anodynizing agent when administered by inhala- 
tion, in the same mode as the vapor of ether, was made since the 
greater part of this work was printed, the subject being only briefly 
noticed at page 427, note. Extensive trials have clearly proved it to 
be more potent than ether in suspending sensibility during surgical ope- 
rations, painful attacks of a spasmodic character, and during parturition, 
and in some respects to be attended and followed by less injurious 
efi'ects. Its use will, therefore, probably in great measure supersede 
that of ether. But there is one part of its operation, which, although 
recommending it in some instances, might render its use hazardous in 
others. It seems generally to lower the pulse, and, according to my 
experience, often leaves considerable debility and depression of spirits 
after its use. In cases of much exhaustion, therefore, it would seem 
less eligible than ether, which has a more stimulant action ; and in all 
cases in which its influence is required to be sustained for any length 
of time, great circumspection should be used in its administration, by 
constant attention to the state of the pulse, and by withdrawing the 
inhaler so soon as sensibility is sufficiently reduced to avoid pain. It 
appears to me that the object to be sought is freedom from pain rather 
than profound insensibility, and it is obvious that this result can be 
obtained at much less risk to respiration and circulation than that de- 
gree of narcotization which, in abolishing all the cerebral functions, 
encroaches also on some of those of the medulla, and may thus en- 
danger life. The fatal case which has recently occurred in Durham,^ 

' Dr. Simpson has endeavored to show [Lancet, Feb. 12, 1848) that death was caused 
in this case, not by the chloroform, but bj the brandy administered to restore animation, 
and which, there being inability to swallow, passed into the larynx, and caused asphyxia. 
The appearances after death were undoubtedly those of asphyxia, with fluid blood in the 
right cavities of the heart; whereas in animals poisoned with chloroform, the blood is 
found coagulated. (Dr. Bennett, Monthly Journal of Medical Science, Jan. 1848.) That 
the insensibility induced by the chloroform favored the occurrence of asphyxia, I think, 
however, is proved hj the absence of cough on the administration of the brandy. Even 
in weak persons, so long as the medullary function is active, any stimulant applied to the 



462 ON THE USE OF CHLOROFORM. 

as well as various experiments on*animals, show that death may result 
from the undue operation of this agent. It is only reasonable that it 
should take its rank with opium and other potent drugs, which are 
remedial or poisonous according to the doses and condition of the sys- 
tem in which they are exhibited. 

In one respect the insensibility from chloroform or ether differs from 
that from opium and other powerful narcotics ; the soper comes on 
rapidly, and ceases quite suddenly, so that the senses are regained all 
at once, as after a deep sleep, and the person is quite free from all 
drowsy feelings. Now, although this transient duration of the soper 
may be partly ascribed to the agent in a volatile state being easily dis- 
persed, yet it also seems to indicate that the suspended sensorial func- 
tion resembles profound sleep rather than coma, and perhaps depends 
on a partially interrupted circulation through the brain (§ 670). 

glottis would excite violent coughing, which would expel the offending matter. Here, 
then, is a reason for not pouring any liquid into the mouth of a person in the state of 
insensibility. 



THE 

STUDY OF GENERAL PATHOLOGY, 

THE 

PKOPER FOUNDATION OF PEACTICAL MEDICINE. 



EXTRACTED FROM AN INTRODUCTORY LECTURE ON THE PRINCIPLES AND PRACTICE OF 
MEDICINE, DELIVERED AT UNIVERSITY COLLEGE, OCT. 1, 1842. 



[The following extracts from an introductory lecture were prefixed 
to the first edition of this work, and they are appended to the present, 
not only to explain the relations which the subjects of this volume bear 
to other departments of medical knowledge, but also to repeat to the 
profession a statement of what the author considers to be the true rea- 
sons why practical medicine has not fully profited by the advancement 
of science, a question which has recently been discussed with much 
ability by Drs. Forbes, Combe, and others.^] 

State of Practical medicine^ as a stud?/, and as an art.— Favor shown 
to empiricism hy the public. — Irksome and difficult character of the 
study of medicine as usually taught. — Insufficiency of empirical 
and nosological medicine. — Some knowledge of general pathology 
at length gained in practice. — Need of general pathology in the 
study and practice of medicine. — What is general pathology ? — 
Its contributions from all departmeiits of medical science, espe- 
cially clinical medicine. — General pathology the proper introduc- 
tion to special pathology. — Where principles fail, experience must 
be the sole guide. — Noble nature and objects of medicine the best 
encouragements to its careful study. 

I must farther state another circumstance which makes me especially 
anxious to use my best exertions in teaching the 'subjects of my course. 

^ Most of these writers apj^ear to me unduly to depreciate British medicine, which can 
scarcely be said to be truly represented by the class of either practitioners or publications 
which have led to a sweeping condemnation of the whole system, and to revolutionary 
demands for a "Young Physic." On these subjects I would record my entire concurrence 
with the sentiments expressed by my able and excellent friend Dr. Symonds, of Bristol, 
whose lettei-s [British and Foreign Medical Review, Oct. 1846, April 1847) I pai'ticularly 
recommend to the attention of the reader. 



464 ON THE NEED OF PRINCIPLES IN MEDICINE. 

It is, tlie loiv position ivliich this most important i^ art of medical science 
still holds luith the public, and even with students. I feel this to be a 
matter of such moment, that, with the hope of rescuing it from such 
unmerited depreciation, I propose to make the chief subject of this lec- 
ture, the state of practical medicine, as a study, and as an art. 

Compare the state of the practice of medicine with that of anatomy, 
physiology, and chemistry — the great fundamental or preparatory 
studies. How minute, how precise, how connected and definite, are 
these ! Yet how loose, indefinite, uncertain, unconnected, is the prac- 
tice of our art ! To the public it appears altogether vague — without 
any acknowledged principles. 

Is there any wonder, then, that quackery should triumph ? that the 
public show their want of faith in legitimate medicine by their ready 
belief in any novelty that is not legitimate ? Thus, one year, St. Johu 
Long's plan ; another year, homoeopathy; another, Morison's pills: 
another, the water-cure — rules the fashion. The public may show 
their ignorance by such credulity; but th^y show also the want of some- 
thing plain and trustworthy in regular medicine. The public will not 
believe that the secret of the art is with a faculty which professes to 
follow experience only. The quack also can appeal to his experience; 
and that too, in a way more striking and convincing than those who 
express doubts and admit difiiculties. Thus, one who cures nervous 
diseases can calculate his success by the numerical method. In eight 
thousand cases he can count only twenty failures. Another tells you 
of an extraordinary percentage of success in cases of deafness, in 
which the most eminent practitioners had failed, &c. Hence you will 
find the partisans of quackery far more zealous in the defence of their 
favorite notions than others are in support of the regular art. No 
wonder that homoeopathy and the water-cure have their royal and noble 
advocates. Then there is a captivating simplicity in the theories of 
quacks. A certain high official personage pins his faith to an empiric 
who was formerly a gardener, and whose notion is, that all diseases 
proceed from buttercups. This is the theory ; every man, woman, 
and child, eats mutton, beef, or butter, or drinks milk ; every cow and 
sheep eats buttercups with its grass ; buttercups are rank and acrid 
weeds ; ergo, all diseases proceed from buttercups. How beautifully 
simple ! How attractive, too, are the comprehensive views of the 
hygeist and the water-curers ! They both agree in their pathology ; 
all diseases arise from bad matter in the blood ; they only differ in 
their mode of expelling it from the system. One purges out the pec- 
cant humor ; the other washes and sweats it forth. There is some- 
thing, too, very fascinating in the notions of homoeopathy ; similia 
similihus medentur. Who cannot fail to admire the expansive genius 
of Hahnemann, who discovered that the best cure for a disease is the 
influence which caused it ? 

On the other hand, the regular practitioner has nothing so plausible 
or so captivating to bring forward in explanation of his method. He 
either has no theory at all, and grounds his practice on experience (in 
which we have said he is matched by the empiric), or, if he gives a 
theory, it is viewed only as an opinion no better than the hypothesis 



ON THE NEED OF PRINCIPLES IN MEDICINE. 4b5 

of the quack, in an art so little founded on principles as medicine. So 
little favour does medicine receive from the public in its pretensions to 
science ! 

How is it with the student? Surely the practice of physic must be 
as interesting as it is important to the student — the useful application 
of all his knowledge — the winding-up of the drama of his studies — the 
rehearsal of the great performance of his life. Surely this must be a 
very attractive study? Quite the contrary. I believe it has been 
generally considered by students as the heaviest, most repulsive, most 
tedious of all subjects (with, perhaps, a single exception). Without 
the constant appeal to the senses with which anatomy attracts and 
rivets attention ; without the beautiful connections and adaptation of 
means to ends which make p%szoZo^?/ interesting; without the simplicity 
and striking phenomena which give a charm to chemistry, the practice 
of medicine, as taught, is an enormous mass of dry detail; its science, 
mere glimpses into an unknown land; its rules, irregular tracks through 
a wilderness of confusion. Practical medicine is studied only from a 
conviction that it is useful and necessary; and not because it is easy or 
agreeable. 

Farther, there are a great many students, certainly not the most indus- 
trious, who shirk the disagreeable duty, pleading that it is neither use- 
ful nor necessary; and that tlKf practice of medicine is only to be learned 
at the bedside, with whatever aid books can supply. It would speak 
more in favor of this opinion, if its advocates acted up to their dogma, 
and proved, by their constant and diligent attendance in the wards of 
the hospital, that they seek there the knowledge which they profess to 
be unable to obtain in the lecture-room. But, so far as my observa- 
tion has gone, I do not find this to be the case. It is not those that 
neglect the lectures, but those who most regularly attend them, that 
prove to be attentive students in the hospital. 

But, although useful and necessary, it cannot be denied that the 
study of the practice of medicine, both by books and by lectures, is at 
first very difiicult and irksome — more so than other studies. But why 
is it so ? This is a serious matter. Let us examine a little into it. 
Is the fault in the imperfect state of the subject, or in the method by 
which it is taught ? The science of practical medicine is undoubtedly 
very imperfect ; but I think it can be shown that there is a still greater 
imperfection in the method by which it is taught. 

As anatomy and physiology, with chemistry, are the studies prepara- 
tory to medicine, one might expect that they should be made funda- 
mental to that of medicine ; that, starting from the knowledge of the 
healthy body, as taught by them, the transition should be easy and 
intelligible to disease — first, in its lowest degrees and simplest form ; 
then to the more compound, pronounced, and more removed from, but 
still comparable with, the healthy standard. Instead of this, lecturers 
and writers plunge at once into the mazy thickets of inflammation and 
fever — subjects so complicated, so changed from anything taught by 
previous study, that anatomy and physiology afford little help ; and no 
wonder that the student (like many observers and reasoners on the same 
topics) becomes confused and bewildered in the complexity of the sub- 
30 



466 ON THE NEED OF PRINCIPLES IN MEDICINE. 

ject ; or, if lie do make out anything, it is something isolated, abstract, 
about fever or inflammation itself, without its natural relations to health 
and to other diseases. 

This plan of proceeding may be compared to a person beginning the 
study of mechanics with the steam-engine; or to the student of chemis- 
try commencing with organic matter. 

The general result is, that where any distinct notion of disease is 
acquired, it is one not at all founded on previous physiological know- 
ledge, but it is a new idea of disease as an absolute, separate thing — 
not a mere condition consisting of altered function and structure, but 
a being, the character and history of which are to be detailed like that 
of a plant or an animal. And when special diseases are treated of, the 
same individualizing process is pursued through all the jargon of the 
schools. Each has its nosology, classification, and definition ; its pre- 
disposing, exciting, and proximate causes ; its theory, ratio symptoma- 
tum ; its diagnosis, prognosis, indications of cure, fulfilment of these, 
jiivantia et Isedentia^ and prophylaxis ! 

With all this formidable array to each disease, the practice of physic 
was an arduous study in the days of Cullen. What must it be now, 
w^hen the diseases of Cullen's nosology have been almost doubled, and 
the facts relating to them have been more than doubled ? 

But let us follow the student, well crammed with his nosological list, 
their definitions, &c., to the bedside. Let us see how his knowledge, 
so meritoriously and laboriously obtained, will serve him in the hour of 
need. In a few cases of fully developed and well-marked acute diseases, 
such as pleurisy, scarlet-fever, or rheumatism, he may get on pretty 
well ; but in the commoner description of cases, acute or chronic, in 
their early stages, in their endless variations from peculiarities of con- 
stitution or from complicating causes, he finds himself continually 
puzzled ; the phenomena do not correspond with any of his defined 
diseases ; they frequently change their character in a way that he 
cannot account for ; his prognosis is falsified ; his diagnosis fails ; and 
his treatment, although not always unsuccessful, does not answer ac- 
cording to his expectations; some patients recovering whom he expected 
to die ; others dying, or not improving, whom he expected to recover. 

Disappointed in the failure of his nosological learning, the young 
practitioner more and more mistrusts it, and falls into a routine of em- 
pirical practice. Without troubling his head about the name or nature 
of diseases, he thinks solely of their treatment ; and, begrudging the 
time that he has spent with books and lectures, he decries everything 
that is not practical. 

Still, he is obliged to retain some notions of the theory of disease ; 
but they are general notions, and not fettered by definitions. He still 
studies symptoms ; he seeks in the pulse and heat of skin indications 
of fever and inflammation ; he looks to the tongue and alvine evacua- 
tions for proofs of disorder of the digestive organs ; he judges by the 
complexion and muscular strength the state of the constitution. In- 
stead of troublesome scholastic definitions, he uses convenient, general 
terms, which may be taken in a pretty vague sense — such as irritation, 
congestion, constitutional weakness, cachexia, disordered digestive or- 



ON TEE XEED OF PRINCIPLES IN MEDICINE. 467 

gans, scrofula, scorbutic habit, and the like ; and his remedial measures 
are designated in the same convenient general terms — such as soothing, 
cooling, supporting, stimulating, alterative, purifying, &c. 

In short, he has, in practice, learned himself, in a loose way, at the 
expense of previous studies, and sometimes, it is to be feared, at the 
expense of some bad practice, "what he ought to have been properly 
taught as the foundation of his studies — general pathology. Thus we 
are led to the presumption that general pathology is the proper basis 
for practical medicine ; and I venture to affirm that a chief reason why 
the practice of medicine has been commonly so distasteful, and so dif- 
ficult in its study, and so unsatisfactory when tested at the bedside, 
is, because its foundation, general patliology^ has not been efficiently 
taught. 

We have just met with a practical illustration of the truth that gene- 
ral pathology is a more efficient help at the bedside than such know- 
ledge of diseases as is to be obtained only from nosological definitions 
and details. Before I proceed to exemplify this truth, by matters of 
every-day experience, let me first briefly point out why it is so. 

"Without the connecting link of general pathology, practical medicine 
derives little or no aid from anatomy and physiology. Instead of being 
founded on them, it is studied and practised quite independent of a full 
knowledge of them, and is generally acquired in proportion as they are 
forgotten. This*kind of practical medicine is much the same as that 
of old women and nurses ; it consists chiefly of treating symptoms, or 
groups of symptoms (called diseases), by remedies that have been found 
useful in similar cases, without the trouble of inquiring about the causes 
of the symptoms, or the precise seat of the disease. Thus, if a person 
complains of headache and giddiness, leeches are applied, purgatives 
are given, because they have been found useful in similar cases. An 
intimate knowledge of the structure and functions of the contents of 
the head would give no farther help in the use of these remedies ; nor 
suggest others, if these be found to fail. If they do fail, the only re- 
source is in experiment ; first one thing is tried, then another, until 
much mischief may be done, or at last, perchance, the right remedy 
may be hit upon ; and this maybe the very opposite of those first used. 
Long experience may make the symptom-treating practitioner more 
successful, if he be an observing man ; because it will acquaint him 
"with additional symptoms to be considered for the guidance of the 
treatment. But there are few of this class of practitioners who are 
carefully observing men, who do remember and profit by their expe- 
rience ; they more generally, like their sisters, the nurses, keep pretty 
close to their first notions ; and although age and the nam.e of expe- 
rience may screen their failures, alas for the young adventurer who 
sets sail on this tack ! 

But the benefit of such experience is gained at the commencement 
by the student of pathology. He has learned to trace symptoms to their 
causes. Having been taught, by anatomy, the peculiarities of the cir- 
culation in the head — and by physiology, confirmed by clinical ob- 
servation, that this circulation may be similarly impeded by opposite 
causes, inanition as well as fulness, he is prepared to find out, through 



468 ON THE XEED OF PEIXCIPLE5 IX 3IEDICIXE. 

other symptoms, which is the cause of the headache in the ease before 
him ; and he adapts his remedies accordingly. 

In fact, a true pathology, or sound principles of medicine, is the em- 
bodiment of the results of experience in disease, with a knowledofe of 
structure and function in health. It is the only connecting link between 
the preparatory sciences and practical medicine. Without it, these are 
disjecta membra; with it, they form a connected body of science — 
young yet, it is true, and falling short of the objects of the art, but 
already ayailable for much, and needing only the growth and continued 
support of its chief members, especially anatomy, physiology, and 
clinical observation, to become the perfect and efficient director of 
practical medicine. 

The great proof of the practical utility of general pathology is, the 
aid which it gives in the study of clinical medicine, and the light which 
clinical medicine continually throws on it. The states which the prac- 
titioner has to treat are often too indefinite or too mixed to correspond 
with any of the definitions of special disease. They frequently consist 
of functional disorder, varying with time and circumstance, or changing 
its place, so as to present no fixed characters. But, compared by the 
pathologist with the standard of health, and analyzed from their com- 
plexity, their nature becomes intelligible, and their proper treatment 
obvious, so far as means are possessed to counteract or control that 
which is wrong. Let us take one out of many exatnples. The dis- 
ordered state of health, for treating which Mr. Abernethy gained such 
a reputation, is one of the commonest ailments we have to prescribe 
for: some call it, with Abernethy, "all stomach;"' others, "liver:" 
others, "disordered constitution;" others, "indigestion;" but, how- 
ever differently they may name it, few refuse to treat it, as Abernethy 
did, by regulated diet, blue pill, and mild saline aperients, repeatedly 
administered. Kow the pathologist analyzes the symptoms of such a 
state ; and, in the white or yellowish furred tongue, morbid eructations, 
tender epigastrium, sometimes full right hypochondrium, with extended 
dulness on percussion, the discolored feces, the high-colored and turbid 
urine, he finds proof of congestion and disturbed secretion of the liver 
and upper part of the alimentary canal; and he recognizes in the 
remedies employed, means which, by increasing the secretions, relieve 
the congestion ; and if these fail, he can suggest other measures which 
he knows to be efficacious in removing congestion, and restoring the 
natural secretions. Again, what confusion in diagnosis, as well as in 
practice, has arisen from comprehending, under the specific name of 
hysteria, the most opposite and most varying conditions, merely because 
they are consorted with some nervous phenomena ; so that this word 
becomes almost synonymous ^ith. female diseases. But, pathologically 
considered, the confusion in diagnosis, and, in some measure, the per- 
plexity in regard to treatment cease. In one group of such cases, the 
pathologist finds really such signs of disordered uterine function as 
would justify the name; other symptoms, however varied, taking 
their origin from this disorder ; and he thus discovers the necessity 
of directing the treatment to this cause. In another group, again, he 
finds the uterine function impaired ; but this only in common with other 



ON THE Is'EED or PRIXCIPLES IX MEDICIXE. 469 

functions ; and all this in consequence of a want of blood throughout 
the body, which want is denoted by the waxy complexion, the pallid 
lips and gums, the loose yet easily quickened pulse, the panting breath, 
the feeble limbs, &c. Here the restoration of the blood is the obvious 
indication; and in proportion as this is effected, the symptoms of nervous- 
ness, debility, and loss of function, disappear. In a third group of 
cases, called hysterical, the pathologist discovers the opposite condition, 
that of sanguineous ijletliora^ which, independently of any disorder of 
the uterus, causes trouble, sometimes in one part, sometimes in another, 
but especially in the nervous system, which, in most females, is pecu- 
liarly liable to disorder. Here, too, he is led to the most appropriate 
treatment. 

This is but one instance out of many that might be adduced to show 
the great practical utility of a good knowledge of pathology. In fact, 
the leading rules of practice, those which guide the most experienced 
men (although many are not aware of it, and would not acknovr'ledge it), 
are founded on general views of diseased function and structure — that 
is, general patJiology. You will not find that practical men treat a 
disease merely according to its name, or according to the nature of the 
local mischief. Inflammation is not always to be combated by blood- 
letting, nor hemorrhage by styptics. The condition of the system — 
that is, of the functions, is to be taken into account ; and the variations 
of this condition, the states of sthenia and asthenia, tone and debility, 
excitement and depression, plethora and anaemia, are the very subjects 
which general pathology explains and shows how to treat. 

I say, practitioners do act more on general ideas of disease than on 
their knowledge of particular diseases. They feel the pulse and the 
skin, to guide them in the use of bloodletting, w^hether they have 
found out the special disease or not. They examine the tongue, and 
inquire as to the state of the evacuations, to guide them in the use of 
purgatives, under whatever complaint the patient labors. They con- 
sider the complexion and bodily strength in connection with dietetic 
measures ; and the chief treatment of convalescence depends on rules 
suggested by general pathological knowledge. 

There are other very important departments of medicine which are 
comprehended in general pathology, and with it have been too much 
neglected — I mean, the study of the causes of disease and their modes 
of operating on the living body (etiology)^ and the means by which they 
may be avoided or counteracted, mclMdcmg prophylaxis^ or the prevention 
of disease ; and hygienics^ preservation of health. Neither of these 
subjects can be satisfactorily comprehended without a sufficient know- 
ledge of the elements and laws of disease. 

Is it not, therefore, most important that these general views, which 
are so practical and so extensive in their application, should be well 
founded and carefully studied? Is it right that the leading doctrines 
of disease, leading, not in theory but in practice, should, as hitherto, 
be left to be picked up irregularly, from casual retrospects of study or 
experience, when they may be learned as the very groundwork of prac- 
tical knowledge? 

What, then, is this general pathology, which we extol so much as the 

30* 



470 ON THE NEED OF PRINCIPLES IN MEDICINE. 

proper foundation of practical medicine ? Let us first state what it is 
not. It is not a collection of hypotheses hung on solitary facts, and 
ingeniously devised to explain this or that symptom, or the modus ope- 
randi of this or that remedy. It is not anything floating on (I cannot 
say, founded on) conjectural notions in anatomy and physiology, such 
as the existence and circulation of a nervous fluid, the presiding influ- 
ence of the ganglionic system, or the vital attractions and repulsions 
of the circulating fluids ; notions which, however they may hereafter 
be substantiated, are at present too speculative to form a founda- 
tion for pathology. Nor is it a partial set of opinions, erected on one 
only of the many pediments of fact on which the science of medicine 
should stand. Healthy anatomy, physiology, physics, chemistry, the 
study of clinical medicine, that of materia medica, morbid anatomy — 
neither of these alone can furnish a foundation for pathology — that 
foundation must be formed by all — the facts whicii all supply consti- 
tute the material of which it is built, and the general facts or laws of 
all must be brought to bear on the arrangement of these materials in 
the construction of a system of pathology. 

Some advancement in these contributory departments is necessary 
before the work can be begup, and it is because they have advanced, 
that the opportunity is afforded. Why should the science of medicine 
remain in a state of powerless infancy, when its members are progress- 
ively acquiring strength and maturity ? Why should the art of medi- 
cine still be groping about in blind empiricism, and an unintelligible con- 
fusion of facts, when science even now can afi"ord it the beginnings of 
light and of order ? 

I have just said that the contributory sciences are sufficiently 
advanced to be generally applicable to practical medicine. * The proofs 
of this in detail, will, I trust, appear in the progress of the course ; but 
I will adduce here a few examples of a prominent kind. Disease, in 
so far as it is the result of mechanical change, or in part made up of 
mechanical elements, may be properly treated by mechanical means. 
It was the knowledge of this fact Avhich led Dr. Arnott to invent that 
admirable contrivance, the water-bed, by which disease is often pre- 
vented and removed ; and he has lately made another application of 
physical science ; in modes of applying pressure to parts with such 
equality as to control to any degree the circulation of the blood through 
them, and thus to relieve pain, remove congestion, subdue inflammation, 
heal ulcers, disperse swellings, and arrest the growth, if not to effect 
the removal, of tumors and other morbid productions. Disease, so far 
as it is physical in its nature and in its effects, is to be investigated by 
physical means. Hence the advantage of acoustic science in assisting 
us in diagnosis of internal disease, and of optical science in enabling 
us to witness the minutiae of its operations and its products.- I need 
scarcely add, that the treatment of disease is in some instances founded 
on, and in most cases guided by, knowledge thus obtained. 

As an example of improvements in anatomy and physiology bearing 
on practical medicine, I may mention the late researches on the nerv- 
ous system, and especially those of Dr. Hall. By these, much that 
before was unintelligible in diseases of the nervous system has been 



ox THE-XEED OF PRIXCIPLES IX MEDICIXE. 471 

satisfactorily explained, and their diagnosis and treatment have received 
proportionate aid. Considerable light has been thrown on diseases of 
the liver and of the heart, by recent anatomical and physiological in- 
vesticrations of these orojans. 

The aids afforded by chemistry to the materia medica have been long 
acknowledged, and continue to increase ; but chemistry is growing in 
importance in its applications to every department of practical m.edicine. 
It is now directly useful in the diagnosis and treatm.ent of diseases of 
the urinary organs. It furnishes a key to the most important rules of 
diet, in health as well as in disease, and bids fair to supply much that 
is wanting in explanation of the origin of many maladies, and the most 
direct mode of preventing them. It is through the aid. of organic 
chemistry, now far advanced — advanced, too, mainly by the labors and 
genius of an illustrious chemist, who this day honors us with his presence 
(Professor Liebig) — that we may hope that experimental physiologists 
and clinical observers will be enabled to solve some of the dark pro- 
blems of the operation of medicines ; a subject replete with practical 
importance, yet one that still lies chiefly in the region of conjecture. 

It will not be disputed that clinical observation has lately done much 
for the advancement of the science of medicine; and this, not only be- 
cause it is the test by which the contributions of other branches are 
tried, but also because in itself it is carried on with the minuteness and 
precision which are essential to science. This precision must apply, 
not only to the modes of calculating facts, but also and most particu- 
larly to the correct determination and classification of these 'facts. 
The accuracy of counting is a mere facility in common arithmetic. 
The accuracy of observing and arranging the facts to be counted is the 
higher and rarer quality. Both are required in the prosecution of 
clinical research. 

The whole department of practical medicine teems with examples of 
the benefits which it has derived from morbid anatomy. AVhat should 
we know of the nature, products, and tendencies of inflammations, and 
other diseases which alter the structures, but for the scalpel revealing 
them to our very sight and touch? The minuteness with which it 
(morbid anatomy) has been pursued in connection with clinical observa- 
tion, in regard to diseases of the lungs, heart, liver, kidneys, and ali- 
mentary canal, deserves especially to be mentioned as the great source 
of our improved theory and practice in these complaints. 

It is not a general or superficial knowledge of any of these funda- 
mental sciences that will avail to make them profitable to medicine. 
It is where their facts and laws have been carefully studied, in relation 
to the living body, that the advantage has become practical ; and this 
study has in many instances developed new phenomena, which reflect 
light also on the contributory science. The application of hearing to 
the distinction of diseases has given rise to a more intimate knowledge 
of acoustic science. Some of the most interesting facts and laws of 
organic chemistry have resulted from researches instituted with refer- 
ence to the investigation of disease ; as, for example, those of Prout, 
"Wohler, and Liebig. In regard to anatomy and physiology, the in- 
stances are abundant. For example, the researches of Charles Bell, 



472 ON THE NEED OF PRINCIPLES IN MEDICINE. 

Foville, and M. Hall, on the nervous system, and those of Astley 
Cooper on the testicle and mamma, were conducted with express refer- 
ence to diseases of these organs, and were often suggested by the 
knowledge previously possessed of these diseases. In this respect they 
followed John Hunter, who throughout his anatomical labors had an 
eye to pathology, and by observing disease, was continually guided to 
objects for these labors. 

So we shall find, as we proceed to the details of pathology, that sub- 
jects which require farther research are continually presented to us in 
a practicable form ; and I shall take occasion to point out these as 
they occur, in the hope that some among you may be induced to cul- 
tivate ground which is rich in promise of important practical results. 

Do not suppose, because I insist strongly on general pathology 
being the proper basis of practical medicine, that this will lead us to 
neglect the superstructure, special pathology. Individual diseases will 
be the chief subjects of the course, occupying 100 out of 150 lectures; 
and I trust that their details will become much more comprehensible 
by the arrangement into wdiich general pathology will enable us to 
distribute them. It is because I feel the vast importance and extent 
of our knowledge of individual disease, that I would endeavor to intro- 
duce you to it from the most advantageous and commanding position ; 
and that position is afforded by a previous acquaintance with the 
general features of disease. In fact, individual diseases are like the 
leaves and boughs of the tree, of which general pathology constitutes 
the trunk and great branches — all preserving an identity and connec- 
tion, yet each portion having peculiarities of character which require 
separate study. Or medicine may be compared to a great edifice, the 
foundation and chief entrances of which represent pathology, which 
generally give the proper approach to the separate rooms, special 
diseases. To some of these, in the imperfect state of the structure, 
there may be access only by the dark back ways of blind experience, 
which then must not be neglected ; but this is no reason for continuing 
to make these dark hack ways the only entrance. 

Throughout our examination of the details of disease, we shall find 
the principles of general pathology continually exemplified ; and 
through these principles the mind can master the details to an extent 
wholly unattainable by those who pursue them as unconnected matters 
of fact. Those who begin the study of practical medicine by attempt- 
ing to learn the details of diseases, are like those who would endeavor 
to master all the facts of chemistry without any knowledge of the 
general facts or laws of chemical action, affinity, and definite propor- 
tions ; yet even in practical chemistry, or chemistry applied to the 
arts and manufactures, the most extensive and important services have 
been obtained from these very principles, applied to the details. 

But in treating of individual diseases, although we shall find our 
previous pathological principles of great use in explaining and simpli- 
fying the details, we are not to be tied to them whensoever experience 
varies from those principles, or goes beyond them ; then, experience 
must be carefully followed. There is no subject in which this simple 
statement of fact is more frequently necessary than in regard to the 



ON THE NEED OF PRINCIPLES IN MEDICINE. 4M 

modus operaiidi of medicines. It is quite true that many curious 
speculations have been offered on this subject. In fact, it seems to be 
quite the hobby, or the Pegassus, of a very speculative class of men 
who call themselves practical. These can tell you to a nicety how 
mercury cures syphilis ; how opium causes sleep ; on what precise parts 
of the intestinal tube each variety of purgative acts, &c. But, as in 
most of such hypotheses, there is much more of fancy than of fact ; 
and as the fancy, if erroneous, may be mischievous in a strictly prac- 
tical matter, I shall be excused if I prefer giving you the naked mat- 
ters of fact. 

The purpose of lectures on the practice of medicine is not merely to 
convey knowledge of disease and its treatment, but also to direct the 
mind in the ways of using this knowledge, and of acquiring more. 
Books will supply details which cannot be given in the lectures ; but 
the more important additional source of information is clinical instruc- 
tion. This is an essential part of the teaching of practical medicine. 
It is its demonstrative part, and is essential, not only because, like 
other witnessed phenomena, it appeals to the senses, but also because 
it is necessary to practise those senses in the examination of the signs 
of disease, and to exercise the reasoning powers in the interpretation 
of those signs, and in the farther application of previously acquired 
knowledge. As general pathology is the connecting link between the 
preparatory studies and practical medicine, so clinical instruction is 
the step between the knowledge of medicine and the personal applica- 
tion of that knowledge in actual practice. I need not say that each 
of these is most necessary to the formation of a good practitioner ; but 
there are especial reasons why clinical study, connected with the prac- 
tice of medicine, is more indispensable now than it ever was. In former 
days, medicine was little more ih.i\n a matter of routine; and the 
examination of a patient was summed up in feeling the pulse, looking 
at the tongue, and asking a few questions as to the feelings and func- 
tions, and this was often done for the sake more of form than of in- 
formation ; for the pills and draughts were much the same in most 
cases. This was little better than quackery, and required no great 
preparatory study. That it sometimes succeeded to win the favor of 
the public is not surprising, seeing that quackery often had a similar 
or greater success. Then the ignorant practitioner could disguise his 
emptiness by a cloak of mystery, and a solemnity of manner, and could 
command confidence by dropping a hint about his experience, tact, and 
intuitive perception of disease. But, ignorant as people still are in 
medical matters, they are not so dull as to be deceived by these means. 
They have a smattering of physiology and the use of remedies, and they 
are become troublesomely inquisitive ; and if they are taken in, it is 
by the clever quack, who is ready with his theories and persuasive pro- 
portion of cures, and not by the unsatisfactory regular, who examines 
but little, and cannot explain his views or his practice. In short, the 
public look for what they have a right to expect, thoroughly educated 
practitioners, who prove their qualifications by their careful method of 
investigating disease, the clearness with which they give their opinions, 
and the general correctness of those opinions. 



474 ON THE NEED OF PRINCIPLES IN MEDICINE. 

This, then, is another reason for thoroughly availing yourselves of 
practical instruction, especially in the clinical department. The great 
importance of this department has occasioned the adoption of extended 
measures for teaching it. I trust that you will prove, by the assiduity 
and success of your practical studies, that the college has not adopted 
these means in vain ; but that, as in the preparatory branches, so in 
the finishing of your medical education, you will obtain that high 
standard of qualification, that must insure the confidence and esteem 
of those among whom you may exercise your calling. 

Gentlemen, we have great pleasure in meeting you again for the 
session — those who have favored us before, as old friends ; new-comers 
w^e welcome to the work, which although arduous, is not one of drudg- 
ery. I almost envy the pleasure, in young and ardent minds, of rising 
step by step in knowledge, and delighting in the wonders and beauties 
of the enlarging view. I admit that the ascent is arduous — that it 
requires hard labor, and no little self-denial. But is there no com- 
pensation in the delight of acquiring knowledge and intellectual power? 
No gratification in learning and contemplating the intricate beauties 
of the most perfect part of the creation ? Is there no moral and reli- 
gious good to our own minds in tracing out and unveiling its frailties, 
w^eakness, decay, and death ? No satisfaction in learning of means 
which a gracious Providence supplies for preventing and removing the 
ills which flesh is heir to ; for relief of pain, suifering, and weakness, 
and restoration of health and strength ? And if from present studies 
you carry your anticipations onwards to their final object in practice — 
under Heaven, yourselves to ease suffering humanity, and to invigo- 
rate and prolong life — is the pursuit less noble, or less worthy of your 
highest thought ? Need I say more for the intellectual and moral 
greatness of our art ? 

Is a study noble in proportion to the breadth and depth, and diver- 
sity of the knowledge on which it is founded ? Then, think of medi- 
cine; how she levies her contributions from every branch of knowledge. 
The human body exhibits a machinery so 'perfect, that the most skil- 
ful mechanical philosopher may take lessons from studying it. It 
contains a laboratory so diversified, and chemical processes so subtle, 
that therein the ability of the most expert chemist is far surpassed. 
But the knowledge of the student of medicine must go beyond that of 
the mechanical and chemical philosopher. He must study those vital 
properties of which they can tell him nothing. He must become 
acquainted with the attributes of life operating in matter. In animal 
generation, nutrition, growth, secretion, motion, and sensation ; in the 
variations of these processes, in their decay, and in their cessation, 
which is death, he has a complicated study, peculiarly his own, in 
addition to those of a more elementary nature. He has, besides, to 
contemplate the body under disease, and to bring to his aid the three 
kingdoms of nature, and almost every art and every science, for agents 
and means to counteract and control that which disturbs its well-being. 
But is the body the only object of his care? No. Mind and matter 
are too closely combined to be studied or treated apart. To medicine 



ON THE NEED OF PRINCIPLES IN MEDICINE. 475 

alone it belongs to contemplate and to treat the entire man — physi- 
cal, MORAL, AND INTELLECTUAL. What Can I Say more of the intel- 
lectual greatness of our art ? 

Neither shall I strain your thoughts far to remind you of its moral 
worth. See its effect on masses of mankind, displayed in the progress 
of the happy discovery of Jenner ! See how even barbarous people and 
idolaters, Mussulmans, Hindoos, and Chinese, respect our nation only 
for the medical aid which it can supply. So that it has happened that 
medicine has become the handmaid of religion — a bond between coun- 
tries, a peace-maker between nations. 

But let us not vaunt ourselves. Listen to one who speaks of our art 
— and that one the eloquent ambassador from the United States, the 
Honorable Edward Everett. I quote from the Times of the day before 
yesterday: "For what was that which constituted the chief pride and 
glory of the British nation ? They had heard of the intercepted letter 
from one Chinese chieftain to another; and what was the characteristic 
which had excited the admiration of the mandarin of a great and im- 
portant empire, reeling at the time under the blows of the British 
government? Was it the steam-vessels of war reaching coasts in de- 
fiance of the desolating simoom ? Was it their arms — their artillery — 
their skill of engineering, which civilized nations now brought to the 
strategy of war ? Was it this, or any of these, which had struck with 
wonder, and awe, and admiration, the barbarians of China ? No ! It 
was the humanity of British physicians and surgeons — their manage- 
ment of hospitals, and the generous kindness which was extended to 
the sick and wounded, even of a hostile nation, which moved them with 
astonishment, and excited their sympathy and regard. These were 
some of the arts of peace which extorted the admiration of an enemy, 
and which other states would do well to imitate." 

But if you would see the moral influence of medicine depicted in its 
liveliest hues, I would ask you to contemplate a domestic scene — a 
family whose hearts are wrung with a dreadful anxiety for one vibrat- 
ing between life and death. What a ministering angel does the physi- 
cian seem ! How they watch his every look ! With what breathless 
earnestness do they hang on his words ! and those words, how they 
wing themselves to the souls of the hearers for sorrow or for joy ! Yet 
such scenes are passing daily and hourly in every class of society — in 
the mansion and in the cottage ; they open the hearts of all ; for the 
moral influence of medicine is bound up with the treasures of life and 
health, and with all those endearing ties that make t^iese treasures 
doubly precious. Nay, how often, with the hopes, or fears, of a blessed 
or an awful eternity ! 

Do not think me too enthusiastic, nor overrating the profession you 
have chosen. Morally and intellectually I cannot overrate it ; and 
now, at the commencement of a new epoch of your studies, when toil 
and exertion are required, I would cheer and encourage you, by re- 
minding and convincing you of the intrinsic gratification which these 
studies may afford, and of the nobleness of the objects for which they 
prepare you. 



476 



ON THE NEED OF PRINCIPLES IN MEDICINE. 



It is the fashion to decry our profession — to call it a poor profession, 
a degraded profession. If it be poor and degraded, is that the fault of 
the calling, or of those who practise it ; or rather of those who should 
have governed and protected it ? Is the art of healing in itself less 
noble, because its practitioners, unsupported by the arm of civil power, 
and too often unsustained by a consciousness of their own dignity, have 
not raised it to the place in society which it ought to hold ? Poor it 
may be, slighted it may be, but degraded it cannot, shall not be, so 
long as its foundation is science, and its end the good of mankind. 



THE END. 



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